Posts Tagged nursing homes

So When Does This Become a Crisis?

I walked into the Emergency Department one hot morning a couple of weeks ago and found every last stretcher — twenty-five beds, including the two we try to reserve for trauma or codes — was filled with admitted patients; furthermore, five additional patients were waiting for consultants and likely admission. We were operating at 120% capacity even before the usual gamut of ED patients would begin flooding in.

Trying to manage an ED under these circumstances is like walking through an open field holding an umbrella during a thunderstorm. You know lightning is going to strike, and you hope like hell it doesn’t strike you. As charge nurse you start re-triaging the patients already under your management. Which admitted patients requiring cardiac monitoring can be safely parked in the hallway (in violation of fire codes) to make room for the syncopal vag bleed at triage? Which chest pain gets the last monitored bed? Is that MVC the paramedics rolling in nothing or a multisystem trauma?

And then, nurses providing care at the front-line begin to get frustrated and angry, because all of them chose to be ED nurses (as opposed to med-surg nurses), and they have lots of expensive education to validate their choice. In the event, they are helpless watching their elderly admits decompensating before their eyes.

Even more seriously, the sudden arrival of a trauma or a patient coding in the waiting room means a scramble to find room; in a scenario when seconds count, delay could be disastrous if there is no available bed to treat them. I don’t actually think the general public understands the fine line emergency department nurses and physicians walk between successful outcomes, where the patient is treated, made well, and discharged, and the morgue. Every health care professional in the ED practices with their heart in their throat and their licences over the fire.

So when does this become a crisis?

We’re told the principal cause of ED overcrowding is patients waiting for long-term care blocking acute-care beds. Not quite coincidentally the Toronto Star recently published an article about the appalling treatment an elderly woman received at the hands of a nursing home called Upper Canada Lodge in Niagara-on-the-Lake. The woman, named Sylvia Bailey, had a broken tibia which was left by nursing home staff untreated for twenty-three days.* She later died because of complications related to the fracture, and the case is now subject to a coroner’s inquest.

The two issues are not unrelated. Health care for seniors is vastly underfunded, and it’s reflected in both the number and quality of beds available. As a society we tend to give a lot of lip service to the care and support we give to seniors. In reality the frail elderly are at the bottom of the health care food chain. They aren’t glamorous or fashionable or have carefully managed public-relations campaigns associated with them. How many people do you see wearing a bracelet or ribbon for proper health care for seniors?

I tend to be quite cynical about this. The elephant in the room is that care for seniors is expensive, and no politician seems to be willing to state the obvious: provision of even adequate supports for a growing population of senior citizens is going to take a considerable mobilization of financial resources, i.e. increased taxes. Politicians love adopting seniors as a apple-pie issue. But given the current political climate which informs us we’re over-taxed, nurses are over-paid,and  the health car system is bloated, and throw in dodgy financial calculations by every provincial political party, any politician who tells you the case of Sylvia Bailey shall never be repeated, and ED wait times will magically disappear is flat-out lying.

So again, when do we decide this is a crisis?

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*College of Nurses of Ontario, are you listening?

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In Which I Write About Stupidity (and Some Facts About This Blog)

Nothing  substantial today — sore tired brain — other than to note that Leisureworld, purveyor of high quality,  compassionate nursing home services in southern Ontario, has issued a dividend.

Also this stupidity:

Kouris’s 83-year-old uncle is one of 11 seniors with dementia who are set to be moved to Sudbury after their mental health centre merges with a new hospital and loses beds in January.

The list of those being moved is constantly changing as the patients improve or worsen, and some could learn at the last minute whether they get to stay or go, a hospital spokeswoman says.

The 130-kilometre distance between North Bay and Sudbury makes it hard for family members — many who are seniors themselves — to make the trip.

I get that the LHIN makes the decisions about bed allocations, but this isn’t Toronto, where shifting beds around makes little difference for access. 130 kilometres in the winter. Frig.

And also, the Double Down makes its appearance in Canada, because, clearly, another fast food item loaded with salt and saturated fats is indicated in a market starved of fast food items loaded with salt and saturated fats. KFC is choking a little on the marketing:

Even KFC doesn’t recommend having the sandwich too often.

Dan Howe, chief marketing officer for Yum! Restaurants Canada, which operates KFC, says the sandwich is a quote — “occasional, indulgent” eat.

Do KFC outlets have automated external defibrillators, you know, for people who overindulge? Just asking.

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I also note that there’s been — well, not a flood, but definitely more than a rainfall that blocks up the storm sewers — of new readers here lately, and I thought I would remark on my blogging particularities and eccentricities, so no one is surprised, ‘k?

1. I post something daily, except when I don’t.

2. When I don’t post, it’s because I’m doing something else, like working or not writing. Or tending to the husband. Or writing something non-blog related, or simply because my brains are running out of my eyesockets trying to think of a clever and concise way to relate the chaos, funny and serious that usually surrounds me. If I fail, you will read me whine about it, forcefully, the next day.

2. Saturdays I usually post poems. And photographs.

3. Personal writings that some deluded people call “poetry” are liable to appear without notice.

4. Pictures of the cat are liable to appear, again, without notice.

5. Sundays I try to post something portentous.

6. I will post a list ‘o links if I am pressed for time, or (more likely) have nothing to say. These tend to be irregular.

7. More personal details can be found here.

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Blatchford Bashes Health Care and Misses the Point [Part II]

[Continued from yesterday.]

In the end, the problem I have with Blatchford’s column is that it seems exploitive of Mrs. Conley and her daughter. I’m not clear Blatchford isn’t using Mrs. Conley to push her own agenda, i.e. Canadian Health Care as the Fifth Horseman of the Apocalypse. In subjecting the case of Mrs. Conley to a somewhat capricious interpretation of facts and events, Blatchford ends up losing sight of the larger point: care for seniors in Ontario is disgraceful, and fixing it will mean higher taxes.

I’ve written on this first point repeatedly. I’ve seen it up close and personal: seniors from nursing homes, euphemistically and erroneously called “Long Term Care Facilities”, dehydrated and septic, poorly thought out advanced directives, limbs rotting away because no one thought to look under the occlusive dressing and on it goes. Services between hospital and community and hospital and nursing home are notoriously poorly articulated. If you need to spend your last years in a nursing home, your lot will often be misery and suffering, unless you have money or excellent family supports.

Hospitals, in particular, are the last and worst place for seniors, yet we continue to warehouse the elderly in acute care beds till we can find a place for them in nursing homes. At Acme Regional Heath Centre, where I work, around 25% of inpatients are frail seniors awaiting placement. Acute care beds are hideously expensive, so this represents an enormous cost to all hospitals. The chances of elderly patients acquiring a nosocomial infection are large, leading to higher morbidity and mortality.

And frankly, while hospitals do acuity well, when it comes to complexity, they suck. You come in with a heart attack or a broken leg or a kidney stone, we will fix you up and send you on your way. These are acute problems and relatively quick to resolve. Complexity takes time, both in practical treatment and care and in disposition. If you’re a nurse on a medical floor, an average frail elderly patient will not be as acutely sick as a heart attack, but requires more treatment in terms of positioning, skin care, managing foley catheters, feeding, restraints, bathing, walking, and medications. Acute care floors are poorly set up to offer this sort of care. If you’re admitted as a Failure to Cope, with a long list of chronic medical problems, social issues, no family to help, maybe dementia, this requires the mobilization of numbers of experts and outside agencies to treat you: not only the regular hospital phalanx of health care professionals, but social work, discharge planning, home care, nursing homes, and of course, family.

However, I can’t say with confidence services delivered by out of hospital providers is satisfactory. Home care in some parts of the province is plainly inadequate and strapped for resources, and nursing homes aren’t much better. Wages and benefits for nurses in home care and nursing homes are abysmal compared to hospital nurses, and one can’t help but wonder if this impacts patient care.

The Ontario government nibbles around the edges of the issue: the Ministry of Health has issued direction, for example, to ensure more seniors are discharged home from hospital to home with adequate community supports, such as help with meals or housekeeping, in-home physiotherapy and so on. There’s plenty of evidence seniors do better at home than being institutionalized. But the bigger problem is that in a system is strapped for resources, improving efficiency and processes can do a lot, but it’s not a panacea.

Unfortunately, in an era when spending and deficits are the focus of all governments, money to build and support the infrastructure necessary to keep seniors healthy and whole will be lacking. It is not just a case of the provincial government not having the political will to properly care for seniors. Do you think any government, of any political flavour, would risk suicide by proposing a substantial tax increase to fund proper services for the elderly?

This is the elephant in the room that no one will talk about: providing proper care for seniors is going to take significant and sustained expenditures now and into the future. In short, good care for seniors = higher taxes. I’m sure it will be a very cold day on Satan’s front porch before you would see Christie Blatchford, or even the editorial apparatus of the Globe and Mail, argue for that.

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Blatchford Bashes Health Care and Misses the Point [Part I]

There was something bothering me about this column by the Globe and Mail’s Christie Blatchford, published a couple of weeks ago. It contains the the semi-standard Tale of Woe in Canada’s health care system. To précis the story, it concerns the travails of Hilda Conley, 84, previously well, hale and hearty, apart from a “benign” brain tumour and two cysts; she was admitted to the untender mercies of Stevenson Memorial Hospital in Alliston, Ontario for a “minor” urinary tract infection; she was held beyond her discharge day over a weekend for a swallowing assessment; she subsequent suffered, due to either nursing stupidity or malfeseance or maybe both, what sounds to be a haemorrhagic stroke related to a choking incident; subsequently in a coma, she developed bedsores; her daughter repeatedly asked for a “special mattress”, more frequent dressing changes, and also a “feeding tube”, because Mrs. Conley was beginning to recover to the point of “speaking”. In the meantime, the hospital and/or staff  “basically left [her] to starve” for five weeks.  In the end she was discharged home with a decubitus ulcer the “size of a fist” with, evidently no home care arranged. It sounds like a typical case of a senior abused by the system, and then cast out to cope on her own.

I don’t doubt that all of this occurred in some fashion. But I don’t think it’s simply a case of a fit elderly woman, with all of her faculties, with minimal health issues, who was chewed up and spit out by the health care system. The specifics of the story don’t jive with what I understand of how the heath care system or hospitals work. But first a few preliminaries. I don’t work at Stevenson Memorial and I know nothing apart from what Blatchford reports. This suggests the principal problem in Blatchford’s reporting : the reader is getting only one side of the story. Blatchford does, in fact, speak with an administrator at Stevenson Memeorial, and adds some snark about the hospital’s “minimal response”: one gets the impression of a tepid or fearful interview, but haughtily dispensed. What Blatchford doesn’t tell you, and what the administrator surely told her, is that the hospital cannot disclose details of Mrs. Conley’s case to the media. Patient confidentiality is not just an excuse; it’s a legislative requirement. In that light, we have the (perhaps justified) grievances of the patient’s daughter, and nothing else.

But it is in the details provided, I think, which present a considerably more complex picture than Blatchford suggests. Some instances:

1. “Benign” brain tumours are not trivial, as Blatchford implies; they are only benign in the sense they are not malignant. They can and will continue to grow, compressing and shifting healthy brain tissue, ultimately causing neurological issues.

2. Patients, even elderly patients, are generally not admitted for “minor” urinary tract infections. This suggests to me, at least, there were some other problems in Mrs. Conley’s health or social/living arrangements Blatchford doesn’t remark on, or perhaps the “minor” bladder infection wasn’t quite so minor.

3. Being held for two days over the weekend for “a swallowing test”, frankly isn’t credible, unless again, there were some other co-morbidities Blatchford doesn’t disclose. Beds in any Ontario hospital are too much at premium to hold patients for this one diagnostic. But in any case, this particular test wouldn’t be ordered unless there was a strong suspicion this poor woman was having difficulty swallowing, and perhaps needed further intervention. Difficulty swallowing is a pretty significant health issue. It impairs nutrition and can lead to aspiration, that is inhalation of chewed food and/or stomach contents into the lungs.

4. Which is apparently what happened, in turn causing Mrs. Conley to choke and made a “blood vessel break in her head.” This is, of course, immensely unfortunate. Blatchford is pretty clear in her column that staff (nurse?) incompetency led to this sequence of events. Perhaps. But equally it is easy to imagine a scenario, where the patient was discharged home (as Blatchford implies she should have been), choked on her dinner, and had a stroke. Or maybe the bleed was completely unrelated but coincidental to the choking incident, but perhaps as a consequence of the “benign” brain tumour. Who knows?

5. Quite a lot is made of the “special mattress” not being provided, the implication being the hospital and/or staff  was being wilful in its refusal to provide one. Unfortunately, it is the rare hospital indeed that provides any sort of special mattress for patients at risk for bedsores. Two very practical reasons for this: difficulty in cleaning, leading to issues in infection control, and cost. (Personally, I usually advise families of patients with breakdown in skin integrity to purchase a relatively inexpensive egg crate pad, which can be taken home and reused.)

On the rest of Mrs. Conley’s stay in the hospital I can’t surmise. I don’t know if Mrs. Conley, for example, was truly “left to starve” receiving only intravenous fluids, or got some version of Total Parenteral Nutrition, or even got some sustenance orally. Blatchford doesn’t tell us. It strikes me as unbelievable that any nurse would deliberately starve a patient, or not strongly advocate for her patient, but that’s just me. However it’s significant Blatchford chooses to drag out some old steroetypes of nurses to evoke a poignant response to Mrs. Conley’s suffering: we’re either all Nurse Ratched or plain dummies. “Stupid, lazy RNs” is a frequent meme in the Comments.

Undoubtedly, there were some issues with Mrs. Conley’s care. Blatchford mentions issues that imply poor oral hygiene, and missed feedings. From a nursing perspective, these need to be addressed. The suffering of Mrs. Conley was enormous. But I don’t think it was entirely at the hands of the hospital or its nursing staff. Clearly, Mrs. Conley apparently had some pretty significant health issues even prior to her admission. Being treated for a urinary tract infection in the hospital setting implies her condition was not “minor”. Mrs. Conley’s co-morbidities complicated her course of treatment in hospital. Blatchford would have us believe Stevenson Memorial almost killed Mrs. Conley.

The truth, I fear, is more nuanced.

[Part II tomorrow]


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Dead Alive Dead [Updated]

Emergency Medical Services — the paramedics, in other words — use a radio system called the patch telephone (which I am sure is not the correct technical name for it) to advise us of patients who are coming to the Emergency Department. Usually these are the critically ill, need-immediate-intervention-and-treatment patients, but sometimes not. The other day we got a patch about a patient that was definitely in the Not category. The patient had died in the ambulance, and EMS was requesting permission to proceed directly to the morgue.

This happens more often than you might think. The frequent scenario is that a patient already dying is sent to the Emergency because — let’s put the best spin on it — the nursing home staff has convinced the responsible physician the patient cannot be cared for appropriately in the nursing home setting (thus rendering superfluous, of course, any strictly delineated “No Transfer to Hospital” directives from the family), or else the patient is dying at home, and the family suddenly decides they can’t cope. In any case, it must be an ugly, unpleasant way to die, bouncing along in the back of an ambulance on, say, the 401.

Imagine our immense surprise, then, when the EMS crew arrived with the patient at Triage, the monitor faintly beeping. (What, she got better?) The nursing home had in fact decided the patient — who was a DNR and a “No Transfer” — had been “poor” for the last few days, and needed “a little IV fluid to perk her up.” EMS found her unconscious with agonal respirations, and on the way to the Emerg, she died. Literally. I saw the rhythm strips myself. Asystole. For a very lengthy period of time, long enough, anyway, for the paramedics to call to ask for the morgue key.

And then, claimed the paramedic, the ambulance hit a bump on the highway — and presto! she had a heartbeat again.* When she arrived, she was in an idioventricular rhythm. Not a great rhythm, but a rhythm and a thready pulse. But more importantly, she was not breathing spontaneously. Her pupils were already fixed.

She really was dead, but her heart hadn’t gotten the message yet. So we quickly off-loaded her into a Resus Room bed, and her heart stopped a few minutes later.

Again, it needs to be reiterated: this is a very crappy way to die. It astonishes me that nursing homes, which are supposedly equipped to deal with the frail and elderly, can’t cope well with the inevitable outcome of frailty and age.

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*[UPDATE] Okay, on reflection, the medics may have been pulling my leg a little on the bump. Maybe.

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I Visit a Foreign Emergency Department

Okay, foreign, as in to a hospital I was not familiar with, which is sort of like (but not really) travelling overseas. Me and my wrecked ankle. Not my Emergency, mostly because some little bird told me a (figurative) bomb had exploded at Acme Regional’s Emerg, and I didn’t want adding to the clots of patients in the hallways. Going to strange Emergency Departments is always entertaining and informative, and so it was.

Arrived at 1034. (I kept notes in the margins of the most recent issue of Harper’s, where, incidentally there’s an excellent article on autism. And also, you might observe, became one of those freaky people who keeps notes about their Emergency Department visits. Emerg nurses will know what I’m talking about.)

Triaged at 1036.

Registered at 1041. Triage Nurse: “Tell the registration clerk to send you directly to xray.”

Taken by wheelchair to radiology from registration by what looked to be a 90 year-old volunteer (who wheezed as she pushed) at 1044.

BTW, this is NOT my ankle

Four views of the ankle at 1054.

Returned to waiting room at 1101.

Brought in by the doc himself at 1124.

Discharged at 1131. No fracture, by the way.*

I thought: Hot dog, this is how Emergency Departments are supposed to work. Patients shouldn’t be sitting in waiting rooms for hours on end, being tortured by Dr. Phil on the tube and tattered issues National Geographic twenty years out of date?

But most EDs don’t work like this. You see, it was dead quiet, as in bereft of patients, empty, unpopulated, shoot-a-cannon-down-the-corridor-and-hit-nothing, uninhabited, vacant, barren, and void. There were no admitted patients lolling about, taking up space and beds. Actual lumps-and-bumps patients, like myself, flew in and flew out. More acutely sick patients could be seen expeditiously.

We’re told constantly by the Ministry of Health that the issue of Emergency Department waits is complex and layered, which I take is Ministrese for There is No Real Political Will to Fix the Problem.

Actually it isn’t that complex or layered. This is how it works: long term care beds are in short supply, which means that patients waiting for placement are blocking acute care beds in hospitals, which means admitted patients spend days rotting the Emergency Department.

There are fixes around the edges of the problem, such the standard preventative care approach (i.e. healthy people use less services), but also such ideas as facilitating supports for in the community through Home Care, so the  frail elderly can stay out of nursing homes and live at home longer — and which has been shown to have better outcomes anyway. But in the end, what’s really required are more long-term care beds, lots more, because the demographics are not on our side. Unfortunately, the provincial government doesn’t seem too keen on providing them.

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*And thanks for all the messages of concern and support. Yesterday was a wretch. I’m being told I was a little bitchy yesterday. (Narcs help.) Nurses are the worst patients, aren’t they?

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Do Old People Have Rights?

I don’t mean in the theoretical, warm-fuzzy, it-says-so-in-the-policy-manual-so-it-must-be-true, everyone-has-rights sort of way. I mean in hard practice: do the elderly really have autonomy to determine their own treatment? Illustrated in two recent cases I had, the short answer is No.

Case 1. Female patient, 94, previously competent, but in nursing home for other medical problems, arrives via EMS as an apparent CVA. A CT confirms a massive cerebral bleed and the patient later dies on an emergency stretcher in the Resus Room. Her advance directives, signed by the patient herself, clearly state “No transfer to hospital” and “Palliative measures only”.  The nursing home, when questioned why this patient was transferred to hospital against her wishes — which in fact is the whole point of having an advance directive — can only say she was “unwell” and the nursing home physician “ordered her to be sent to hospital.”*

Case 2. 84 year-old female, who again has well-documented advance directives forbidding transfer to hospital previously written by the patient herself, but now has Alzheimer’s dementia, presents as a possible urosepsis. The nursing home says the patient was sent to the Emergency at the “request of the family.”

These aren’t hypothetical cases, and ones similar happen with dismal regularity. Physicial frailty means, in the minds of some, means mental incompetence. Advance directives are frequently subject to the capriciousness of nursing home staff or family members. In point of fact, the ability of anyone practically to direct their own care if incapacitated is limited. Even strictly delineated advance directives can and will be overridden by families and by health care professionals.

The nursing role in all of this is threefold: to educate patients and families on advance directives, to facilitate provision of services, including providers like home care, pain management and palliative care, and finally, to advocate for the patient. Whether we actually do it, of course is another question. Working in the Emerg, you frequently get the impression that expediency or convenience (or even laziness) trumps good patient care.

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*The game, according to a colleague used to manage a nursing home, goes like this: The nurse in charge simply calls the nursing home physician, advises of  patient’s condition, but “forgets” to tell the doc of the advance directive. The physician of course then orders the transfer.

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Saving JM from The Republic of Health Care Stupid

It’s been my firm belief in life that picking up the phone is always trouble.

I’m lurking innocently the other day around the ward clerk’s desk when the phone rings. The ward clerk is out smoking, I think, in the ambulance bay with the other ward clerk — they have a mutual pact to quit before the New Year and are absolutely sucking out every last tobacco-filled pleasure — and since there is no else but me and the ringing phone, I pick up.

“Acme Regional Emerg,” I mutter as indistinctly as possible. I’m hoping they think it’s the pizza place down the road and call back.

“This is Hilda from Windy Sunset Nursing Home.”

Great, I think. “Yes?”

“You sent back a patient yesterday with orders for Home Care. He’s supposed to get IV meds once a day. Do you know him?”

Uh, no. In the first place, I wasn’t actually here yesterday, the warden granted a day pass, and secondly do you know what percentage of the GTA’s population we see everyday? And also I am getting worried. Being an old emerg nurse, I know Trouble when it’s walking on tiny cat feet, and this has all the signs and symptoms of being a tiger. Or at least a puma.

I look around. There is neither ward clerk nor charge nurse I can pass this impending mess off to. I sigh. Let me pull the chart, I say and call you back.

I hang up. I now officially own the tiger. Or puma. I find the chart,and yes, there it is. JM is an 89 year-old guy, bedridden, Alzheimer’s dementia in its last ugly stages, who has somehow developed an elbow cellulitis that has engulfed much of his left forearm. And hey, there’s an order for Home Care who’s supposed to administer Ancef 1 g IV OD x 7d.

JM has now entered The Republic of Health Care Stupid. It’s a funny little country, this Health Care Stupid. Governed by a cadre of bureaucrats, it’s presided over by a quasi-divine entity called “The Minister”, who lives in a gilded palace called “The Ministry of Health”, where she is fed peeled grapes and allowed out occasionally for ceremonial spending announcements and ribbon-cuttings. Its principal products are regulations and directives, consultant’s reports, and catered lunches.

What? You have no passport for this fabulous land? No matter. You don’t need one. And once you enter, you can never leave!

So. The Stupid:

Home Care steadfastly maintains that nursing home nurses, being nurses and all, can maintain IVs and administer IV medications, and refuse therefore to service nursing homes. And if the nursing homes can’t administer the drugs, then the patient obviously needs a completely unnecessary admission to hospital. Nursing homes (and their nurses), on the other hand, are equally resistant to actually learning how to start and maintain IV lines. As for IV meds — forget it.

Immovable object meet irresistible force.

In short, EMS will have to pick up the hapless JM, and he’ll spend a goodly chuck of his remaining time on this earth being shuffled back and forth between Windy Sunset and Acme Regional Emerg (and costing the system thousands of dollars in addition). This is because Home Care and the nursing home sector have squabbled like dirty chickens for the last 15 years over who actually has responsibility for patients like JM.

Clearly, this is Home Care’s problem, not mine. (It says so on the chart!) There are several Home Care case managers flitting around the hospital. They have a mysterious, near-mythological office up on the 5th floor that no one has actually ever been in. Rumours that a wormhole will suck in unauthorized personages and transport them to a desolate planet with endlessly windy plains presided over by a cold and lifeless sun, or Winnipeg, are, I’m afraid, unsubstantiated. At any rate the case managers are a pleasant, likely lot, except for one I not-so-secretly call La Crusty.

So I call up to the love nest, or particle physics lab or batcave or whatever they call their office. Of course, I get La Crusty, not the nice ones. I explain the problem, the Twilight Zone-ish Predicament of JM. Why exactly won’t Home Care go into nursing homes?

“Snarl, arf growls nutter hiss sbapz, because warf nurrzsarf, snarf, and gnash,” says Crusty.

I see. Well, since the order is for Home Care, maybe you need to come deal with this poor guy et famille because already I am getting very, very tired of this whole business, and hey, I just only picked up the phone. I have my own patients to take care of, though no doubt JM will be mine before the day is done.

Silence. Sound of La Crusty’s head exploding.

I hang up. Fortunately Social Work is hanging around. I am beginning to really love Social Work. Instead of standing around talking about why problems can’t be fixed and then deciding to hold a (fully catered) meeting or ten to discuss further why they can’t be fixed, she actually fixes problems.

Remarkable.

In the end, the family has money, and they agree to hire a private duty nurse to come and give the drugs to JM in a fully staffed nursing home with nurses and everything, and with Home Care services available to any other citizen, so the poor guy won’t have the hell of laying on an ambulance gurney for seven days more or less continually.

Is this how our health care system is supposed to work? Really?

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Epiphany

Went to work the other day, found my assignment was in the treatment rooms, walked in and found I had five admitted patients: two fractured hips, a stabilized DKA1, and a couple of  FTCs/FTTs2. All but one were over 80 and more or less unable to walk.  So you know what sort of day I was going to have — and these were the least acute in the department, which had 27 admits in total.  So.  I was to provide nursing care for four total care patients, complete initial and ongoing assessments and vital signs, copy orders, ride herd on consultants, fling meds, do bed baths, test blood sugars before each meal (3 x 5 =15 glucometer readings), arrange for various and sundry diagnostics, you know, medical floor stuff, and in between, seeing various lumps and bumps in the other five beds.  Which always turn out to be more complicated than the expected —  needing IV starts,  nebs x 3, complex dressings or some such.

Needless to say, the lumps and bumps took somewhat lower priority than the admitted patients.

So I was busy.  Take a number, I hear you saying,  the queue starts here.  I’m not complaining, really.  Sometimes it’s a bit of a break looking after predictable, routine patients:  you get to provide some actual nursing care. No brains, no fuss, no muss.

The trouble is, this is becoming the usual, not the exception.  I’m starting to see admitted patients discharged from the Emerg, as in going the course from ICU to Stepdown to Telemetry to Medicine to home with a script and a specialist’s appointment in two weeks.

The I had an epiphany:  Acme Regional Health Centre doesn’t actually provide emergency services in the space they call the Emergency Department.  What we provide is Outpatient Day Surgery, Home Care Evaluation and Ongoing Treatment, a medical/surgical ward, ICU/CCU services, Pre-op Clinic, Fracture Clinic, Ambulatory Care, Office space for Consultants, Psychiatric counselling and Inpatient Services, and a very special place for GPs (and Telehealth Ontario and nursing homes3) to dump patients.  We only see a few Emergency patients on the side. Our real job is to be the catch-all and cover for the rest of Acme Regional Health Care. We fix what all the bits and pieces of our overloaded health care system can’t — and get precious little thanks for it.

So really (as a corollary) what’s the point of all the elaborate training and the alphabet soup of certifications I have — and not to mention the eons of experience as an Emerg RN?  Is there any point to having Emergency nursing as a specialty when in fact we do very little real emerg nursing anymore?

And why did it take so long for me to figure it out?

Dolt.

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1Diabetic Ketoacidosis

2Failure to Cope/Failure to Thrive: a sort of catchall diagnosis, describing frail elderly patients, who can’t go home, usually because they (or their caregivers) have become physically or mentally incapable.
3One of my most petest of pet peeves are nursing homes who call EMS for their obviously failing patients despite utterly clear, written advance directives that state “No Patient Transfer to Hospital. Comfort measures only to be provided at nursing home.”  And lo! They come anyway.

So I call them on it. The conversation usually goes like this:

Me:  “I’m calling from Acme Regional Emerg, I’m wanting to know why this patient was transferred here.”

Nursing Home RPN: Snarl,  arrrrg, mutter argyfargblah, dehydrated, arf, waaaagh, not eating, waaarg mutter snarf, hiss.

Me: “You did realize that the patient had advanced directives not to be transferred?”

Nursing home RPN: “. . .”

Me: “I mean, was it you who signed the advanced directive form? “

Nursing home RPN:   “We can’t provide appropriate care, snarl aarg, wargf, mutter.”

Imagine, a nursing home that can’t care for dying and/or debilitated patients.

If I had a dollar for every time I have had this conversation I would be somewhere else, like a beach waaaaaaaaay south.

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