Posts Tagged Stupidity

A Nurse Contemplates Leaving the Profession [Updated]

Dinner last night with an old friend who toils in the mines of Labour and Delivery. She has worked there for four years. She told me of an incident not too long ago working the night shift, faced with a post-partum patient who was bleeding, hypotensive, and tachycardic, in short, showing all the signs of going into hypovolemic shock. She was running around, starting IV lines on flat veins and hanging blood products. Packed red cells. Platelets. Cryoprecipitate. And by-the-by, saline by the bucketful. She called for help from her colleagues. Apart from this patient and another who was walking the halls a few hours from delivery, it was a slow night.

Of course, you know the end to this story, don’t you?

No one came.

No one even popped their head in the doorway to ask, “Is everything okay?”

All of  them were at the nursing station, playing Draw Something on their phones, watching the season finale of Grey’s Anatomy, what have you. Too busy to help a drowning colleague with a shocky patient.

My friend went to her educator and her manager. They shrugged it off. No biggie, they said. Clearly my friend had things under control. “The patient lived, didn’t she?” they said. And then: “Maybe you need to improve your organizational skills to handle critically ill patients.”

This last to a 50-something woman who has been nursing 25-plus years, almost all of it in critical care settings.

For my friend, this incident may well be the last straw. She is definitely leaving L & D. Why would she want to stay? The workplace culture on this unit is awful. She feels alone and isolated when going into work. She can’t trust her colleagues. “Why,” she asks, “would anyone want to work there? There is no teamwork. No solidarity. Nurses backstab each other at the first opportunity.”

The only question remaining is whether my friend will leave nursing altogether and take her 25-plus years of experience with her, which included not only the knowledge to provide expert care to patients, but the potential to share that expertise in mentoring and nurturing new nurses. She’s uncertain what she would otherwise do, but leaning towards abandoning the profession which has shaped her adult life. She only needs an out — which she hasn’t found yet. She is that disgusted.

You might tell me that stories like this are unusual and not representative of nursing. Unfortunately, we all know better. So in the end, I don’t blame my friend for wanting to leave. I would do the same.

So what would be your response?

UPDATE: Some comments from Twitter:

@TweeterERNurse @TorontoEmerg I was “spoken to” about helping other nurses too much, as it increases MY pts time in the ER. I applied for another job.

@SqarerootofeviL sad but true.. seen my ma & aunt live it.- “No teamwork. No solidarity. Nurses backstab each other at the first opportunity.” @torontoemerg

@NorthernMurse @TorontoEmerg So how do we change this culture? What do I, as a student and soon new grad, do to improve the #NursingCulture?

@TweeterERNurse @NorthernMurse @TorontoEmerg Learn more than your manager about regulations. Google everything on the inservice boards. Become the expert.

The second to last tweet from @NorthernMurse is probably the relevant question, don’t you think?

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The Insanity of It All

Warning: my semi-annual politicalish post. When I read this, I admit I gawped:

$26,659: Our 2011 Medical Expenses

 Yes, you read that right. And we had insurance coverage for everyone last year, including daughter, 16, and my son who is 23 years old. Let me break it down for you:

    • Insurance Premiums……………..$14,179.04
    • Prescription Costs…………………$ 7,198.00*
    • Doctors Fees, etc…………………$ 2,068.49*
    • Eye care……………………………..$ 404.28*
    • Dental………………………………..$ 2,752.00**
    • Mileage……………………………….$ 300.00

* Costs in excess of insurance coverage.
** No insurance coverage.

Our medical costs in 2010 were $18,636. The principal reason why our medical expenses in 2011 increased by such a large amount was because our insurance premiums increased from roughly $7,000 in 2010 to over$14,000 in 2011.

This same crappy, expensive health insurance will likely be cancelled because my wife’s former employer has filed Chapter 11 bankruptcy and has filed a motion with the bankruptcy court to cancel all medical benefits for retirees and their families. My wife is classified as a retiree because she became disabled as the result of her pancreatic cancer, and the surgical chemotherapy and radiation treatments she received in 2006, and was unable to return to work. The story of her disability is described in detail at this link. Fortunately she is covered by Medicare, but we will lose even this crappy insurance coverage for myself, my daughter and my son.

I have a rare autoimmune disorder that unfortunately was not properly diagnosed until after the time had passed for me to file a disability claim with Social Security. Thus I am not eligible for disability benefits or Medicare. New York has a program for younger children that my daughter for which my daughter might qualify.

Because the insurance exchanges required under the Affordable Care Act will not go into effect until 2014, it is unlikely that my son and I can find insurance until then, assuming that the Supreme Court doesn’t find the ACA unconstitutional.

Basically one large every two weeks for medical expenses. Can any American defender of the status quo tell me why this isn’t completely insane and morally bankrupt? Or any Canadian admirers of U.S. health care — I know you are out there — tell me why the American system is superior in the fair and equitable provision of health care?

Just askin’.

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

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

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

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

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

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

Really.

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

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

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

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When Labelling Patients Causes Patients to Die

I found this story how a homeless woman died very disturbing:

Anna Brown wasn’t leaving the emergency room quietly.

She yelled from a wheelchair at St. Mary’s Health Center security personnel and Richmond Heights police officers that her legs hurt so badly she couldn’t stand.

She had already been to two other hospitals that week in September, complaining of leg pain after spraining her ankle.

This time, she refused to leave.

A police officer arrested Brown for trespassing. He wheeled her out in handcuffs after a doctor said she was healthy enough to be locked up.

The throwaway, disposible patient

She told officers she couldn’t get out of the police car, so they dragged her by her arms into the station. They left her lying on the concrete floor of a jail cell, moaning and struggling to breathe. Just 15 minutes later, a jail worker found her cold to the touch.

Officers suspected Brown was using drugs. Autopsy results showed she had no drugs in her system.

Six months later, family members still wonder how Brown’s sprained ankle led to her death in police custody, and whether anyone — including themselves — is to blame.

There seems to be no simple answer.

Actually there is a very simple answer. At some point in her care, a nurse or physician decided Anna Brown deserved to die. I don’t mean literally a health care professional wrote Anna Brown’s chart, “This patient deserves to die.” But someone decided — a nurse, a physician, or maybe it was a collective, Emergency Department judgment —  that because Anna Brown was homeless, because she was black, because she was poor, because she had made multiple visits, because she was still in pain, because she advocated for herself by making a fuss, because she possibly had (undiagnosed) mental health issues, she was not entitled to proper care.

She was labelled. She was drug-seeking. She was crazy. She was a frequent flyer. And that killed her as surely as if a nurse had bolused potassium chloride.

I will tell you why I think this is true.  Because Anna Brown had made repeated visits, and no one took her seriously. Because she told staff about her increasing pain, and no one believed her. Because she was unable to walk, and no one thought to ask why. All of these are enormous waving red flags for any emergency department health care professional, and neither physician nor nurse did anything about them. That’s the thing about labels: they contain their own little subjective judgements about patient care, and obscure the obvious.

If Anna Brown had been a middle-class white woman with a nice home, a job and a car, I am willing to bet — no, I know the outcome would have been different — or at least, she would not have died, gasping for air, from a pulmonary embolism on a cold jailhouse floor. There certainly would not have been any of this Kafkaesque horror of being in obvious distress with a deep vein thrombosis, about to throw a clot, and being utterly unable to get help at the very place where you might expect it.

I will let the public in on a little secret. We all do it. Each and every one of us. I don’t exclude myself. We all label patients. It is deeply embedded in the culture of health care to the point where it is an accepted practice. We all call patients drug seeking and crazy and frequent flyers and failures-to-die and failures-to-cope. We laugh at them. Hell, there are whole blogs and books devoted to the art of ridiculing patients we have already labelled. (Though when you think about it, there is nothing quite as charming as making fun of  human beings who are powerless, is there?) Has any one ever thought labelling patients might cloud and impair clinical judgment? Or that it dehumanizes patients and is just plain wrong?

There is also this from another blogger who writes:

But the way Brown died was not the result of a few bad choices. It was the result of a myriad of institutional violences: white supremacy, the broken health care system, police brutality and the prison industrial complex, the racism and classism of the child welfare system, ableism and its intersection with racism, dehumanization and criminalization of (suspected) drug users, and the lack of housing as a human right, among others. Anna Brown did not die with the dignity we afford to human beings, but with the contempt we reserve for garbage. And a woman’s humanity is not just forgotten and cast aside with no systemic reason.

[But go read it all.]

Don’t think I have much to add.

[Via.]

[UPDATE: A long time reader suggests instead of the word label, I should use “profile,” as in “racially profiling.” Once upon a time I might have thought the word unnecessarily inflammatory — but now I am not so sure.]

[UPDATE II: Small corrections to syntax. Hobbit not cooperating.]

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Fat Nurses Need Not Apply

A Texas hospital has declared war on the scourge of obese nurses:

A Victoria [Texas]  hospital already embroiled in a discrimination lawsuit filed by doctors of Indian descent has instituted a highly unusual hiring policy: It bans job applicants from employment for being too overweight. 

The Citizens Medical Center policy, instituted a little more than a year ago, requires potential employees to have a body mass index of less than 35 — which is 210 pounds for someone who is 5-foot-5, and 245 pounds for someone who is 5-foot-10. It states that an employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional,” including an appearance “free from distraction” for hospital patients.

“The majority of our patients are over 65, and they have expectations that cannot be ignored in terms of personal appearance,” hospital chief executive David Brown said in an interview. “We have the ability as an employer to characterize our process and to have a policy that says what’s best for our business and for our patients.”

It all sounds so, well, high-schoolish, and I don’t think the CEO is seventeen, though he’s acting like it. I mean, can you get any more shallow? Since when does physical appearance have anything to do with competence or worth or dignity of any health care professional?

Or maybe David Brown doesn’t really believe nurses actually have skills — we just stand around as decoration, lookin’ pretty.

And fitting the  “representational image” of hospital employees to meet patient “expectations?” What the hell does that mean, anyway? If  patients expect this (and this is a pretty common “representation”)

A representational image of a nurse

then hiring practices should make sure all nurses are boobalicious? What if the patients want all-white nurses? Or all females? Or no Muslims?

The man is a bit of a dink, obviously. I can only imagine how valued overweight nurses employed by this hospital must feel.

The article goes on to note that this David Brown, CEO of Citizens Medical Center, has some issues. In 2007  he wrote memo about some foreign-born physicians in which he  stated: “I feel a sense of disgust but am more concerned with what this means to the future of the hospital as more of our Middle-Eastern-born physicians demand leadership roles and demand influence.”  He continued, “It will change the entire complexion of the hospital and create a level of fear among our employees.”

Needless to say, there is a discrimination lawsuit over that.

So let’s summarize what the leadership at Citizens Medical Center believes: scary scary fat nurses scaring patients. Scary scary dark-skinned physicians scaring employees and patients.

Clearly a place where I would want to work. Or be treated.

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Scripting Nurses is Bad for Patient Care

This might be a new low in nursing management. Instead of actually providing caring, empathy and compassion, some hospitals would like nurses to provide a simulacrum of caring, empathy and compassion, believing patients are stupid enough not to tell the difference:

Nurses unions say an increasing number of hospitals nationwide are asking nurses to adhere to standard scripts when talking to patients, down to how often they use a patient’s name (at least three times per shift)

At several Massachusetts hospitals, nurses have been given laminated cards to hang around their necks with the words they should utter at the end of every visit: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’

These particular words, consultants say, are important because of research showing that patients are more satisfied with their care when they believe nurses made time for them. [Emphasis mine.]

This is called “scripting.”  It’s the newest shiny object for nurse managers. The underlying philosophy is that it doesn’t really matter if the nurse in reality establishes a therapeutic relationship, administers a medication properly and safely, completes a thorough and accurate assessment, or does all the myriad (and out-of-sight) procedures and processes necessary to ensure a successful and healing visit. All of that falls by the wayside: what’s most important and valuable is that the patient believes they got good care.

Of course, there is a fairly large gap between reality and belief. When I worked in the United States, my employer was exceedingly concerned with customer relations (I use the phrase advisedly), and regularly called nurses on the carpet for (allegedly) dissing patients. I personally was the recipient of a patient complaint in this regard: she believed I was missing in action for her entire visit. Fortunately I had charted extensively and nearly hourly because she was also receiving some high doses of narcotics and spent most of her visit sleeping. My care, in fact, and I will blow my own horn here, was exemplary. But you see the point. There is no such thing as the completely satisfied patient. It is a myth. The capacity for patients being satisfied on every aspect of their care is nearly infinite. Unfortunately, our capacity to make patients satisfied in all things is rather constrained. Patient care is complicated. It’s impossible to account for every contingency. Furthermore, patients sometimes equate nursing care to hotel room service. Sadly, we aren’t bellhops or waitresses. Trying to achieve patient satisfaction in each and every case  is a ultimately a losing game.

In any case, the value of scripting nurses, at least in the Emergency department setting, might be limited. One study indicates patient satisfaction scores remained constant pre-and-post introduction of scripts in an ED. This suggests to me, anyway, that scripting is just another in a long series of quick fixes for a problem which is actually hides the real elephant in the room: the link between nurse working conditions and job satisfaction, and patient mortality, morbidity and overall satisfaction. Nurse Keith at Digital Doorways excellently discusses this in blog post on the same subject. I won’t rehearse the argument at length, which basically boils down to “happy nurses make for happy patients.

So in the end, do you think treating nurses like idiots would increase or decrease job satisfaction? And how do you think that affects patient care?

[Update: corrections in formatting made. I sometimes forget WYSIWYG blogging isn’t always WYSIWYG.]

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TV Series Hot

Gob-smacklingly stupid or hip advertising? I’m leaning towards the former. Via CBC:

A Stockholm hospital that published an online ad looking to fill a summer position with a nurse who is “TV-series hot” says it was “written to catch people’s attention.” 

“We want people to be curious and have a little imagination,” said Elisabeth Gauffin, head nurse at Stockholm South General Hospital (Södersjukhuset) to the Metro newspaper.

My Emergency department colleagues

The ad read, in Swedish: 

“You will be motivated, professional, and have a sense of humour. And of course, you will be TV-series hot or a Söder hipster. Throw in a nurse’s education and you are welcome to seek a summer job at Södersjukhuset’s emergency department.”

(“Söder” literally means “south,” but here refers to Södermalm, a fashionable district in Stockholm. Think “Soho.”)

The hospital’s nursing manager said the phrasing wasn’t meant to exclude anyone based on looks. 

I (sort of) get what the hospital was trying to do. Readers may have noticed I’m not without a sense of humour. But I’m not sure the “And of course” phrasing of the ad effectively signals the intended irony. It’s a little pathetic the hospital needs to rely on a tired old cliché to recruit nurses. Ultimately, I think, the ad trivializes what nurses actually do in Emergency departments, and reinforces public perceptions and stereotypes. As a well-seasoned RN, I would be somewhat disinclined to work there. But maybe it’s all lost in translation, and the ad is deliciously funny in the original Swedish.

Incidentally, for the record, I am not “TV series hot.” On the other hand, I know to work the buttons on a defibrillator.

[Thanks to my friend Leigh for sending this along to me. Her comment: “Laugh or cry?? Mostly exasperation I think. Add more horror that the survey results show that people think this is appropriate!”]

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A Nasty, Medically Unnecessary, Coercive Procedure

This is just grostesque:

A Republican supermajority has muscled two of the most restrictive anti-abortion bills in years through the Virginia House, despite bitter yet futile objections from Democrats, with one GOP delegate deriding most of the procedures as “matters of lifestyle convenience.”

You want to put what where?

[SNIP]

And the ultrasound legislation would constitute an unprecedented government mandate to insert vaginal ultrasonic probes into women as part of a state-ordered effort to dissuade them from terminating pregnancies, legislative opponents noted.

“We’re talking about inside a woman’s body,” Del. Charnielle Herring said in an emotional floor speech. “This is the first time, if we pass this bill, that we will be dictating a medical procedure to a physician.”

The conservative Family Foundation hailed the ultrasound measure as an “update” to the state’s existing informed consent laws “with the most advanced medical technology available.”

The Oklahoma legislature passed a similar law a couple of years ago. Full disclosure, in case you didn’t know it: I dislike abortion, but I’m strongly pro-choice. Even if you are strongly against abortion on moral or religious grounds, I would like to know how a medically unnecessary, coercive, invasive procedure can be ethically justified in order for a patient to receive health care? (I think we can safely dismiss the Family Foundation’s reasoning as spin.) And if the patient is a 13-year-old rape victim, how is this not despicable and evil?

Another question I would like to ask: if you’re a health care professional, would you excuse yourself from participating or facilitating in enforcing this law?

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A Little Nurse Bashing to Start Your Day

For breakfast, how about some outrageous libel from physician-blogger Terry Simpson (Twitter: @DocSimpson). File this under how not to blog about a serious issue in health care:

The Arizona State Nursing board has asked that this nurse [Amanda Trujillo] undergo a psychiatric evaluation.  The board is charged with protecting the public. The public needs to be protected from “angels of death,” and needs to know if this is the act of an illiterate nurse, or someone who will tend to rogue behavior beyond the bounds of the profession.

Screen shot of yourdoctorsorders.com. Note the gratuitous "psychiatric evaluation" reference.

Note to Terry: I’m not quite clear on how likening a nurse to a mass murderer is not libellous. Or a constructive contribution to an important debate on patient autonomy and nursing practice.* Can you elaborate?

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*Because I think you do raise some issues in your post worthy of debate and discussion — though I might strenuously disagree. You seem to want a serious conversation, but you end up being an ass. Too bad.

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Under Construction

Meaning me, of course.

I worked a (rare) Night 12 a few days ago. It was the usual dog’s breakfast of high acuity, walking wounded without end lining up at Triage, and the particular Emergency Department hell of having no beds for, you know, emergency patients, the department being a stunt double for a med-surg unit. But there was a small ray of hope. Or rather it was okay news-sucky news situation. We were to get  a bed, the element of suckiness resting on the fact the bed was on 5 North, my perennial nemesis, where, I swear, reside the most obstreperous nurses in the history of the Universe.

(Excuses I have heard over the years from 5 North for not taking patients: too busy, patient too sick, patient too combative, patient [with normal vitals] too unstable, patient a drug abuser, patient HIV positive, on break, short-staffed, still on break, patient restrained, patient not restrained, swabs not resulted, patient unsuitable, no one to take report, too close to shift change, just about to go on break, you just sent us a patient, the bed isn’t clean, the patient hasn’t left the bed, the room needs to be cleaned, too late in the night, too early in the morning, the patient will disturb the patient in the next bed, it’s a male bed and your patient is female, still on break — well, I could on.)

So I told the primary RN to call up report. We need to move some patients in.

They won’t take report, came the reply. All the nurses are on break.

“What the hell?!? All the nurses?!?” I was incredulous. “How can all the nurses be on break?”

I called up to 5 North. “Can I speak to the charge?”

“She’s on break.”

“Can I speak to any nurse?”

“They’re all on break.”

“All of them?”

“Yes.”

“Who’s looking after the patients?” As one might imagine, I was becoming a little agitated.

“I am,” came the reply.

“Who are you?”

“I am,” said the voice on the other end, “the nursing student.”

Dear sweet Lord, I thought. “Let me summarize,” I said.  “You’re looking after 24 patients all by yourself, because all the RNs are on break?”

“Well,” said the student in a tone which made it clear she thought she was dealing with a plain idiot, “there’s a nurse sitting beside me.”

‘”Oh,” I said, thinking I had misunderstood the entire situation. “Can I speak to her?”

“No! She’s on break. I told you”

After which I lost it, just a bit. “So when your patient in 55 falls out of bed and fractures her hip because she’s been ringing the call bell for fifteen minutes because you’re trying to clean up the patient in 37, what are you going to do?”

“Oh, I’ll call the nurse to help.”

“But she’s on break!” I was nearly shouting.

Click. The student hung up on me.

Well, I thought. That didn’t go well. But then, after I went home and thought about it, wasn’t I guilty of the same bullying behaviour towards this student I have written about so critically? I heard afterwards I had reduced her to tears. Didn’t this make me the poster child for nurses eating their young? The student, after all, was not responsible for being placed in an compromising position, and being made to run interference against a nasty ED nurse (i.e. me) was fairly despicable. I should have recognized the circumstances and adjusted my own response accordingly — regardless of who answered the phone. In the heat and stress of the moments it’s all too easy to engage in awful behaviour and justify our bullying afterward in terms of providing good care or best practice. It’s all a lie. There isn’t ever justification for bullying. All I can say in my defence: I’m a work in progress. Like everyone

[Update: Yes, I misspelled “construction” in the title. I need a sub-blogger minion to proofread.]

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