Posts Tagged Ontario

Nurses Practice Beyond Their Scope — And It’s Not a Bad Thing

A very good, if obvious, idea on the use of RNs: nurses should be used to the full extent of their abilities. From the Toronto Star (and kudos to the paper for their Nursing Week insert in Saturday’s edition):

“The bottom line is that we’re wasting valuable resources with our RNs,” says Doris Grinspun, the Registered Nurses’ Association of Ontario’s chief executive officer. “European countries like the U.K. have been using RNs to their full capacity for years. It will be a missed opportunity for the public, taxpayers and patients if we don’t move to full utilization of our nurses.”
[SNIP]
[Grinspun] wants the province to recognize the education and expertise of registered nurses, and to agree that they could be doing more within the scope of their practice, like diagnosing patients, ordering diagnostic and lab tests, conducting pelvic exams and prescribing medications.
Though the mandate of Ontario’s action plan for health care is to find ways to maximize the system, full utilization of care providers isn’t possible until the government revamps policies about who can bill for certain medical procedures. “We should be using nurses and all health-care providers to open access, increase the timeliness and quality of care and to contain cost,” she says. “But if a nurse does a pap smear, the doctor doesn’t get paid. If a nurse diagnoses a child’s ear infection and prescribes antibiotics, the physician doesn’t get paid. I go berserk when I see doctors taking blood pressure,” she says. “Nurses have the training to free up a doctor’s time in primary-care settings so she can focus on more complex situations.” Plus, the move to grant registered nurses more autonomy on the job would lower the waiting times for patients to be seen, meaning there will be fewer patients showing up at walk-in clinics and emergency rooms.

Not exceeding their scope of practice

The (somewhat) amusing thing about this idea is that nurses (or least those working in in high acuity areas like ICUs or Emergency Departments) already do all much of this in an highly unsanctioned, unregulated and unofficial way. Let me provide a simple example. Suppose I am triaging an exceedingly anxious patient with chest pain, and decide the patient requires an ECG — which incidentally I can order under medical directives. I explain the test to the patient. I tell her ECGs measure the pattern of electrical activity in the heart and therefore can show dysfunction. I place the electrodes across her chest and limbs, and carry out the test. The printout shows a patient in a regular sinus rhythm with no acute abnormalities.

Do I tell my agitated patient, whose anxiety is growing by the second, that (A) the ECG shows her heart is performing in a normal way and that we need to do some blood tests to confirm everything is okay, or (B) that the physician will discuss with her the results of the ECG when he sees her — which might be in a couple of hours?

When I was a new nurse, some years ago and being a good, diligent practitioner, I would have told this patient (B). This was not to dog my responsibilities or pass off work to the physician. (B), in fact, is the correct answer. Interpreting a test for a patient is considered a form of diagnosis, and in Ontario and most jurisdictions, making and communicating a diagnosis is considered the exclusive preserve of nurse practitioners and physicians.

But this is the deal. I have been educated how to interpret ECGs. I know how to tell atrial fibrillation from SVT from sinus tachycardia. I know what ischemia looks like, and I can spot ST elevations in a steam bath. More importantly I have the judgement to recognize the borderline cases and defer to the physician. Additionally, it seems to me, cruelty, indifference and bad nursing can be defined by a nurse telling a patient — especially one that is anxious —  that she needs to wait to speak to the physician about her ECG because of “the rules.”*

I am not for stupidity in the form of thoughtless adherence to regulation. I am not for cruelty either. So I decided a long time ago, that on balance, it was altogether better for the patient to have this information, rather than sit in the waiting room in a state of high anxiety. Even if my professional regulatory body has officially determined I can’t because technically it is beyond my scope of practice.

And so it goes. Nurses quietly and unofficially violate the scope of practice all the time. We push the envelope. We add blood work we think the physicians have missed. We slip in chest films because we know they need to be done. We order ECGs on patients we don’t like the look of.  We review lab results with patients. We cajole specialists into “having a peek” at a patient if we are worried about them. We tell patients — sometimes in very circular language, to avoid the damning “communicating a diagnosis” — what really is going on.

Why do we do it? Sometimes we know physicians will support us. Sometimes it’s to avoid difficult conversations with physicians, or because physicians won’t listen to the opinion of a mere nurse. (One physician I know of absolutely refuses to order serum lactates on obviously septic patients, because a positive result means she needs to follow a complicated sepsis protocol — even though the literature is pretty clear that early and aggressive intervention in sepsis saves lives.) Bottom line: we do it in the interests of the patient.

Should nurses be permitted to utilize their full knowledge and skills? Absolutely. It’s better for patient care and better for nursing work life. And also we need to formally regulate what nurses do already, to protect nurses themselves.

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*The College of Nurses of Ontario, my professional regulatory body, would probably, and unrealistically suggest the alternative of getting the physician to speak to the patient immediately after doing the ECG as the “proper” course of action. But think about it this way: my ED probably does 30 ECGs (if not more) in the course of a 12-hour shift; if it takes a physician 5 minutes to discuss the results with a patient, then 30 x 5 minutes = 150 minutes = 2.5 hours.  That’s a pretty big chunk of time, and in a busy department, is not going to happen.  And that’s if you could get the physician to come out to triage to see the patients to begin with. It is simply not good use of his time and is completely unnecessary. Which rather demonstrates the point of the article quoted above.

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

Click to enbiggen

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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Andrea Horwath has a Complaint about the Health Care System.

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

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

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

[SNIP]

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

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

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

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

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

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

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

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

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Buskerfest

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

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

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

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

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

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

Comment seems superfluous. More Kate:

Acrobats.

More acrobats.

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

But my favourite? HERE COME THE BUGS!!!

The bugs were great. We loved the bugs.

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

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

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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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Hotocalypse

Hot enough for ya?

For you non-metric types, that 38C is an even 100F. I think I speak for most of my fellow Canadians when I say, “WTF?”

I suppose it’s redundant and unnecessary to add that staying out of the sun, finding a cool, air-conditioned place to hole up in (if possible) and drinking plenty of fluids (alcohol or tea or coffee don’t count in this regard as they tend to dehydrate) is the best way to prevent heat exhaustion or stroke. I really don’t want to see you in my emergency all floppy, syncopal and dehydrated because you’ve decided Thursday is the best day to practice for the triathlon or because you think the lawn needs a little trim before the weekend.

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The Most Useless Form on the Planet

Imagine this: you’ve had the shift from hell, no beds, every other patient is moments away from seeing Jesus/Allah/Buddha and to top it off, the department is down three nurses, another nurse is transporting the multisystem trauma downtown, and you feel really think working conditions were unsafe for both you and more importantly, your patients. So you go to your unit union rep — in the case of most Ontario nurses, from the Ontario Nurses Association — and she says, No problem. Just fill out this document, the Professional Responsibility Workload Form, in either Official Language, in quadruplicate, and all will be well.

Oh, I forgot. Here’s page 2:

So it’s 0730, you’re coming off nights from the shift in which you thought you might finally go postal, and you’re union rep is telling you to fill out this form. The chance of it getting completed? Is zero too high an estimate? Here’s a hint: there’s a four-page guide on how to effectively fill out the form.* And if the form is actually filled out? The union (I think) is supposed to meet with  management to discuss the (completed) form, but in truth I have never heard of any outcome of such a meeting, or if in fact such meetings exist. One suspects when the union raises workload issues with management — encompassing such items as competency, patient safety, you know, important things — management says, “It is what it is,” and with a nod and a wink the union goes off to collect its membership dues. In short, we’ve filled out these forms for as long as I’ve been a nurse, and nothing has ever changed as a result.

It seems, to me anyway, that the Professional Responsibility Workload Form is a classic example of appearing to address an issue, while in fact doing absolutely nothing. Doing so lets both the union and managers off the hook for the deteriorating quality of nursing work life. I don’t think I am being unduly harsh. There is a distinct lack of accountability and transparency around these forms, and it’s symptomatic of a general complacency within ONA’s leadership about issues affecting front line nurse. Given that ONAs 57,000 members each pay nearly a thousand dollars annually in dues, you think someone would come up with a better process to watch workload issues.

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*The statement on the top of the guide made me laugh out loud:

“ONA members indicate it is important and worth the work to complete Professional Responsibility Workload (PRW) Report forms.”

I am not very clear which ONA members the union leadership was speaking to. Not anyone, I’m guessing, from an emerg.

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New Contract Beats Up on Ontario Nurses

On 3 June 2011, an arbitration panel handed down the new contract for the majority of Ontario hospital nurses. The panel was set up when negotiations between the Ontario Hospital Association and the union, the Ontario Nurses’ Association broke down. This is a pretty routine procedure when the union contract comes up for renewal, because in Ontario, nurses are considered “essential workers” and don’t have the right to strike. I’m fairly sure this wouldn’t interest many or even most of my readers — even nurses — except for a obnoxious new contract clause, buried deep in the arbitration award:

Effective April 1, 2011, no sick pay benefit is payable under HOODIP for the first fifteen (15) hours of absence for the sixth (6th) and subsequent period(s) of absence in the same fiscal year (April 1st through March 31st).

English translation: if you have six or more absences because of illness (as opposed to days, it must be noted), your employer will punish you for being sick by docking you fifteen hours of sick pay for each absence.

It is true that nurses have among the highest absentee rate among any employee group, and this clause is an attempt to remediate the situation. It is also true that high absenteeism is for reasons unique to nursing. These are the smartly dressed white elephants you see standing in the corner that the hospitals and the union both ignore: we’re exposed to infectious disease, high stress levels, poor morale and horrendous working conditions. We all know about it, and nothing is ever done but pass the blame to nurses. I can’t see how punishing nurses for factors out of their control is even remotely helpful. It’s a little like starving a child, then beating her when she takes a bite of cake.

Even aside from these generic issues, one can easily see circumstances where the heartlessness of this clause will affect individual nurses. Supposing you had an illness which required specialized treatment over a period of time, such as chemotherapy, which required you to take an occasional sick day. According to the union and the hospitals, too bad for you. We are now, they are saying, going to flog you financially for contracting cancer.

It’s disgusting.

The union will probably say, “Well, it was an arbitrator’s award, it was out of our hands.” This only partly true, at best. The arbitration panel doesn’t pick contract language out of thin air. Both the hospitals and the union make submissions in the arbitration process based on their bargaining positions. Clearly, this little piece of horizontal violence was on the table beforehand. How vigorously did the union contested the hospital’s position on this at negotiations? Who knows. I respectfully suggest, however, that ONA put this clause at the top of its list when new negotiations start in a couple of years.

Unfortunately, ONA has calculated, probably correctly, that the pushback from front line nurses over this clause will be minimal. We can do very little about it, and in any case, there is a huge disconnect between front line nurses and the union leadership — which you would think would be a cause of concern. In its news release, all ONA could offer was some anodyne mush from ONA’s president, Linda Haslam-Stroud. The bash-the-nurse clause was mentioned not at all. “The agreement,” said Haslam-Stroud, “addresses the priority issues of the front-line registered nurses and allied health professionals – the backbone of health care.”

Uh, huh. How about working with the hospitals to fix some of the root causes of absenteeism, instead of tacitly supporting a policy which punishes them?

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Yep, It Was a Disaster

Nurse K had an interesting take on my blog post the other day about dealing with an over-crowded ED: it was a disaster, pure and simple:

In short [she writes] if, really truly, your hospital is using 25/27 beds for admits and there is no way to transfer them out or transferring would be significantly delayed and six critically-ill people are coming in via ambulance…I don’t care what’s going on or what country you’re in, that’s a disaster. Seriously.  If this is your hospital, and people are being shitmonkeys and refusing to assist you, start busting out the triage tags.  Page every administrator out there.  Say you have a disaster and are starting your Disaster Code.  Maybe someone will cancel a meeting if the media starts calling.

I’m not sure if she’s fisking me, engaging in some not-so-gentle mockery, or using my post to buttress her conceptions about the nature of Canadian health care: referring to the Canadian public system as commie-pinko-socialist is probably a clue. In any case the point is taken: it was a disaster. It’s an ongoing disaster. It’s funny how sometimes it takes someone outside the situation to point out the obvious.

I will say, however, that Nurse K’s suggestion to implement the disaster plan — in Ontario, known as a “Code Orange”” — isn’t feasible. In my hospital, at least, it’s a decision that needs to be made jointly amongst the charge, the manager and the ED physician, and  in any case tends to be reserved for external mass-casualty disasters, like busloads of HIV-positive haemophiliacs crashing on the 401, not for severe hospital-induced multi-system dysfunction. So what’s a harrassed, stressed-out charge nurse to do?

Nothing. Get all rowdy with equally harassed and stressed out bed flow managers. That’s about it.

The point is that at my hospital and at many others there is no plan.

Why? Because 1) we cope, and 2) hospital administrators see emergency department over-crowding as “normal”, intractable, and somehow not a serious hospital problem. Both are wrong. We do cope, but we carry on in way an over-heating engine run for a while before it finally seizes up and stops functioning. Sick time and turnover are increasing: not a sign of a well-functioning department. And the problem is fixable. I know the Ministry of Health is working, albeit slowly, on long-term solutions. But somehow, it isn’t better knowing various health officials, flaks and functionaries are busily at work introducing systemic reforms when the problems are much more immediate. If I can think of four or five ways to improve flow of admitted patients out of the ED without even opening new beds or breaking into a sweat, then surely it’s not beyond the grasp of hospital management. All it takes is will and prioritization — which sadly seems to be lacking.

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A Politician in the Emergency Department

From the CBC television show Make the Politician Work. For my American readers, it features New Democrat party leader Jack Layton, a Torontonian, who spent some time hanging with the nurses in a pretty typical-looking Ontario ED at St. Joseph’s Hospital in Hamilton, Ontario — where, incidentally, I was born.

Aside from this historic significance, the video segment itself is pretty unique in that it’s one of the few produced by conventional media related to any emergency department which doesn’t fall over itself pandering to physicians. Nearly all of the people shown are nurses — yes, nurses — doing what we all do in the ED.

(The code blue sequences are obviously staged — holy pathetic chest compressions! — but not maybe not so obviously to the general public.)

[Big thanks to RN Luke for sending this to me!]

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