Despite (or maybe because of) its status as a legal drug, alcohol consumption is nearly culturally universal, as is addiction and abuse, and the health complications of alcohol use occur across the lifespan.
Although recent research has shown that certain races and individuals with specific genetic profiles may be predisposed to alcoholism, defined as physical dependency upon ethyl alcohol (ETOH), the social and psychological aspects of alcohol addiction exist in all races and cultures.
As well, whereas legal consumption of alcohol is restricted in most societies to certain age groups, the negative health consequences of alcohol use effect all age groups. From alcohol-related accidents to fetal alcohol sydrome (FAS) to liver disease, etc., alcohol consumption, excessive or not, results in untold costs in terms of lives and health care dollars.
One group of individuals often ignored when we talk about the effects of alcohol addicition and abuse is, ironically, the addict. News stories and statistics usually track the unintended victims of abuse--sober accident victims, infants born with FAS--but addicts themselves are usually blamed for their problem and therefore the negative health effects of alcoholism upon them are usually assumed to be chosen, inexcusable, unnecessary...ultimately, a drain on the health care system.
For this reason, alcoholics seeking treatment for alcoholism present a challenge of compassion to ER nurses. Usually we treat patients whose injuries or illnesses are unintentional. With alcoholism, we treat an illness that is the result of the patient's volition. Other illnesses are similarly the result of individual's choices--smoking and lung disease, obesity and just about everything else!--but addiction to alcohol (or other drugs) seems a less sympathetic and more dangerous consequence of an obnxious habit.
I focus on the physical aspects of alcoholism and the nursing interventions necessary to protect the patient seeking detox from the untoward side effects not of alcohol abuse but of the detox process, itself. Attention to the psychological aspects of alcohol abuse and addiction is a more proper intervention while the patient is inpatient, not in the ER. Therefore, aside from supporting the patient's decision to seek detox, I leave philosophical and psychological discussions out of my nursing care.
A-B-C-Ds. Not hard. Usually patients seeking detox are functional, at least from the standpoint of body functions.
However, in the secondary survey (a nursing assessment that takes place after the primary ABCs are assessed and intervened, if neccessary), the D indicates differential diagnosis and/or disability. Aside from the psychological difficulty of breaking a habit, there are potential physical dangers to the patient attempting detox. The initial intervention for these occurs in the ER.
Alcoholics are often relatively malnourished and the sudden cessation of drinking can induce biochemical changes with serious side effects. The most serious side effect is seizure activity. Relative deficiencies in various B-complex vitamins due to malabsorption, specifically Thiamine and Folic acid, predispose the patient to seizures.
Nursing, therefore, must intervene by administering these essential nutrients, usually via IV, and engaging seizure precautions: intravenous access, oxygen and suction supplies at the bedside, and the administration of a benzodiazepine. Usually lorazepam is used because it has both sedative/anticonvulsant as well as anti-anxiety properties.
The anxiolytic property is necessary to permit the patient to get beyond the physical effects (mostly euphoria) of alcohol intake that are often the source of compulsive drinking. The more anxiety the patient experiences, the more likely their decision to detox wanes. Successful detox, therefore, relies upon the transient use of a substitute drug.
Basic lab work is also necessary before the patient is admitted. Complete blood count (CBC), comprehensive metabolic panel (CMP), blood alcohol content (BAC, or medical ETOH), and a urinary drug assay.
The rest, of course, is up to the patient. I can treat detox patients but I can't ultimately detox them. They have to do that for themselves.
Tuesday, February 19, 2008
Tuesday, February 12, 2008
(Don't) Dial-a-Nurse
One of the most frustrating aspects of working in an ER is fielding calls from people who want to discuss their symptoms over the phone and expect a diagnosis, home treatment plan, or advice about whether or not to seek emergency treatment. Sometimes these individuals are calling about themselves, but most often it is a parent calling about a child's symptoms.
Ostensibly, my hospital does not permit ER nurses to give advice over the phone. The reason for this is liability. If I gave advice to someone about symptoms I cannot properly assess in person, I run the risk of misdiagnosis or mistreatment or both.
Similarly, I have a 50/50 chance of recommending correctly whether or not someone needs to seek emergency treatment. If I tell them to come to the ER and they do and, in fact, they have an emergent condition, then I might be their hero. But when they are stuck with a bill for an unnecessary ER visit, I'm the villian.
And, worse, if I suggest that they do not have an emergent condition when in fact they do, perhaps life-threatening, and they don't come in, well...
The belief that it is easy to distinguish emergent or life-threatening conditions over the phone is the subject of this short (and scary, to an ER nurse) article.
www.nytimes.com/2008/02/12/health/12magn.html?_r=1&th&emc=th&oref=slogin
Regardless of my hospital's policy, the administration continues to publish the ER's phone number against our requests and will not allow us to have a phone message to answer as many other businesses, doctors' offices, and health care agencies do (a message that usually begins, "If you have an emergency, hang up and dial 911..."), claiming that such a message is too impersonal.
(Ironically, the only department in our hospital that has such a messaging service is Human Resources!)
How do I negotiate this mine-field?
I try to put myself in the caller's place and tell them what I would do if I were experiencing or witnessing the symptoms they are relating to me. Telling them what I would do if I were them or if it was my child strikes me as offering an informed opinion, not advice, and is a reasonable way to communicate what I think but ultimately leave the decision up to the caller.
They should just be happy I don't give them my mother's stock advice: "It'll be better in the morning."
Ostensibly, my hospital does not permit ER nurses to give advice over the phone. The reason for this is liability. If I gave advice to someone about symptoms I cannot properly assess in person, I run the risk of misdiagnosis or mistreatment or both.
Similarly, I have a 50/50 chance of recommending correctly whether or not someone needs to seek emergency treatment. If I tell them to come to the ER and they do and, in fact, they have an emergent condition, then I might be their hero. But when they are stuck with a bill for an unnecessary ER visit, I'm the villian.
And, worse, if I suggest that they do not have an emergent condition when in fact they do, perhaps life-threatening, and they don't come in, well...
The belief that it is easy to distinguish emergent or life-threatening conditions over the phone is the subject of this short (and scary, to an ER nurse) article.
www.nytimes.com/2008/02/12/health/12magn.html?_r=1&th&emc=th&oref=slogin
Regardless of my hospital's policy, the administration continues to publish the ER's phone number against our requests and will not allow us to have a phone message to answer as many other businesses, doctors' offices, and health care agencies do (a message that usually begins, "If you have an emergency, hang up and dial 911..."), claiming that such a message is too impersonal.
(Ironically, the only department in our hospital that has such a messaging service is Human Resources!)
How do I negotiate this mine-field?
I try to put myself in the caller's place and tell them what I would do if I were experiencing or witnessing the symptoms they are relating to me. Telling them what I would do if I were them or if it was my child strikes me as offering an informed opinion, not advice, and is a reasonable way to communicate what I think but ultimately leave the decision up to the caller.
They should just be happy I don't give them my mother's stock advice: "It'll be better in the morning."
Saturday, February 2, 2008
Nursing Compliments
Recently, I completed a recommendation letter for a fellow nurse who is applying to a graduate program in trauma nursing. She wants to become a Clinical Nurse Specialist, similar to a Nurse Practitioner. I've known her for awhile, like her, and thinks she's a good nurse. It was not hard to think of a few good things to say.
But I didn't just want to say "good things." I wanted to say the best thing!
Thomas Merton, a Trappist Monk, once wrote, "Build a chair as if for an angel." His meaning was clear. If you are going to produce something, do it in the best way and for the highest good you can imagine.
Writing a recommendation letter for someone is tricky business. You don't know who will read it. Who are the members of the selection committee? Is there a selection committee? Will the reader be a sticky organizational bureaucrat, or is there room for creativity, levity? Knowing these things is important if one is trying to say the best thing for the circumstances.
I erred of the side of saying the best thing I could say regardless of the circumstances. Along with all the hagiographic blah blah blah, I simply wrote: "I would have no difficulty entrusting Ms. (Nurse) with my patients, with myself as a patient, or with any of my family members as patients."
Certainly the highest compliment one nurse can bestow upon another.
But I didn't just want to say "good things." I wanted to say the best thing!
Thomas Merton, a Trappist Monk, once wrote, "Build a chair as if for an angel." His meaning was clear. If you are going to produce something, do it in the best way and for the highest good you can imagine.
Writing a recommendation letter for someone is tricky business. You don't know who will read it. Who are the members of the selection committee? Is there a selection committee? Will the reader be a sticky organizational bureaucrat, or is there room for creativity, levity? Knowing these things is important if one is trying to say the best thing for the circumstances.
I erred of the side of saying the best thing I could say regardless of the circumstances. Along with all the hagiographic blah blah blah, I simply wrote: "I would have no difficulty entrusting Ms. (Nurse) with my patients, with myself as a patient, or with any of my family members as patients."
Certainly the highest compliment one nurse can bestow upon another.
Friday, February 1, 2008
Hospital O'Hare
I've been a nurse for awhile, and after a few years, like any other job, I've exhausted the opportunity for new and unique experiences. Most of what I do everyday on the job is like what I do every other day on the job. As monotonous as that sounds, at least these ordinary experiences are fun and interesting to me.
That said, I experienced a "first" a few days ago.
When I started working as a nurse, I was on a medical-surgical unit. This is the main nursing floor in most hospitals, a place where patients stay for awhile, either with an illness that is not quickly treated or after surgery, recovering.
What I liked about this sort of nursing was the familiarity of patients from day to day. Often I would have the same four or five patients for days at a time. The length of time I had with them allowed me to build reporte, often finding out more about their ordinary lives, their likes and dislikes, what made them tick. This amount of time also gave me a greater opportunity to influence their thoughts about health habits and how they might change their behaviors to encourage and maintain maximum health.
But this consistency also had some draw backs, the most depressing of which was taking care of really obnoxious patients for days at a time.
In the emergency room, however, I see patients for maybe a couple of hours, half a shift at most (6 hours). This means I see more patients and a greater variety of patients in each twelve hours I work. The trade-off is I also have less opportunity to chat, figure them out, influence their health-related choices.
Not so the other day.
The other day I received report on a patient from the night nurse--the patient had arrived at 0545--and I duly reported off on the very same patient to the very same night nurse twelve hours later. In all, the patient spent fifteen hours in our ER, long enough to develop new symptoms that she hadn't even come in with! That was a first for me.
I attribute this to a scatter-brained, passive-aggressive ER doctor, an internist by training who has no sense of time-management and who has to fix everything about a patient (and sometimes their families!) This doc had patients circling for hours that day--my patient wasn't the only one--like "Discharged from ER" was a busy airport where patients couldn't land. I've seen worse up-in-the-air at O'Hare!
And it was an overtime shift for me...
That said, I experienced a "first" a few days ago.
When I started working as a nurse, I was on a medical-surgical unit. This is the main nursing floor in most hospitals, a place where patients stay for awhile, either with an illness that is not quickly treated or after surgery, recovering.
What I liked about this sort of nursing was the familiarity of patients from day to day. Often I would have the same four or five patients for days at a time. The length of time I had with them allowed me to build reporte, often finding out more about their ordinary lives, their likes and dislikes, what made them tick. This amount of time also gave me a greater opportunity to influence their thoughts about health habits and how they might change their behaviors to encourage and maintain maximum health.
But this consistency also had some draw backs, the most depressing of which was taking care of really obnoxious patients for days at a time.
In the emergency room, however, I see patients for maybe a couple of hours, half a shift at most (6 hours). This means I see more patients and a greater variety of patients in each twelve hours I work. The trade-off is I also have less opportunity to chat, figure them out, influence their health-related choices.
Not so the other day.
The other day I received report on a patient from the night nurse--the patient had arrived at 0545--and I duly reported off on the very same patient to the very same night nurse twelve hours later. In all, the patient spent fifteen hours in our ER, long enough to develop new symptoms that she hadn't even come in with! That was a first for me.
I attribute this to a scatter-brained, passive-aggressive ER doctor, an internist by training who has no sense of time-management and who has to fix everything about a patient (and sometimes their families!) This doc had patients circling for hours that day--my patient wasn't the only one--like "Discharged from ER" was a busy airport where patients couldn't land. I've seen worse up-in-the-air at O'Hare!
And it was an overtime shift for me...
Thursday, January 31, 2008
Fact, Not Fact: Statistics By Any Other Name
I received this tidbit yesterday. Proof-positive that whereas statistics don't lie, people can lie with statistics.
"Guns don't kill people, doctors kill people!
"According to the U.S. Department of Health and Human Services, there are 700,000 physicians in the United States. The number of accidental patient deaths per year is 120,000. Therefore, accidental deaths per physician is 0.171.
"According to the F.B.I., there are 80,000,000 gun owners in the United States. The number of accidental gun deaths per year is 1,500. The number of accidental deaths per gun owner is 0.000188
"Statistically, doctors are approximately 9,000 times more dangerous than gun owners.
"NOT everyone has a gun, but almost everyone has at least one doctor. Please alert your friends to this alarming threat.
"Ban Doctors, Not Guns!"
Okay, so it was sent to me tongue in cheek, but many similiarly ludicrous ideas about safety are based on similiarly silly statistics.
Like this one: You're safer flying than driving because statistically there are more car crash fatalities per year than fatalities in plane crashes. Fact is, the average person travels in a car far more often than they do in an airplane, therefore the likelihood of being in a car accident is much higher. In fact, also, it is far more likely that one will survive multiple car crashes, whereas surviving an airplane crash is far less likely.
Or this one: You're safer not getting a tetanus immunization shot because statistically you're more likely to die of an anaphylatic reaction to the shot than you are of tetanus infection. Fact is, the reason more people die from the shot than from tetanus is not because the shot is more dangerous, but because tetanus infection is rare due to widespread immunization. However, the likelihood of surviving anaphylatic reactions is far greater than surviving tetanus, which, if you get it, has a survival rate of almost 0%.
And if one more person tells me that you're safer in a rollover accident without your seatbelt on because you're less likely to get stuck in your crushed or burning vehicle...
"Guns don't kill people, doctors kill people!
"According to the U.S. Department of Health and Human Services, there are 700,000 physicians in the United States. The number of accidental patient deaths per year is 120,000. Therefore, accidental deaths per physician is 0.171.
"According to the F.B.I., there are 80,000,000 gun owners in the United States. The number of accidental gun deaths per year is 1,500. The number of accidental deaths per gun owner is 0.000188
"Statistically, doctors are approximately 9,000 times more dangerous than gun owners.
"NOT everyone has a gun, but almost everyone has at least one doctor. Please alert your friends to this alarming threat.
"Ban Doctors, Not Guns!"
Okay, so it was sent to me tongue in cheek, but many similiarly ludicrous ideas about safety are based on similiarly silly statistics.
Like this one: You're safer flying than driving because statistically there are more car crash fatalities per year than fatalities in plane crashes. Fact is, the average person travels in a car far more often than they do in an airplane, therefore the likelihood of being in a car accident is much higher. In fact, also, it is far more likely that one will survive multiple car crashes, whereas surviving an airplane crash is far less likely.
Or this one: You're safer not getting a tetanus immunization shot because statistically you're more likely to die of an anaphylatic reaction to the shot than you are of tetanus infection. Fact is, the reason more people die from the shot than from tetanus is not because the shot is more dangerous, but because tetanus infection is rare due to widespread immunization. However, the likelihood of surviving anaphylatic reactions is far greater than surviving tetanus, which, if you get it, has a survival rate of almost 0%.
And if one more person tells me that you're safer in a rollover accident without your seatbelt on because you're less likely to get stuck in your crushed or burning vehicle...
Saturday, January 26, 2008
Types of Patients IX: "Bad Babies"
A touchy subject.
Yesterday, I accepted the care of a 53 day old female with respiratory distress. There is nothing more frightening to me as a parent and as an ER nurse than a baby that can't breathe or isn't breathing well.
As a parent, I recall a time when my infant son choked on a small cracker, and how the minutes he did not seem to be able to breathe shortened my life, I'm convinced, by years.
I recall, too, the several times I have had to resuscitate him when he did not regain spontaneous breathing after having seizures.
There is nothing worse than a child who will not breathe!
As a nurse, flashes of parents' hopes for their child as I care for him or her rush through my head and I realize that I am somewhat the keeper of these. I also become entrusted by the parents as easily, it seems, as one would entrust their poorly running car to a mechanic. I do not want this responsibility, but by virtue of my training and career, I have tacitly agreed to accept it.
Okay. ABCs.
A. Baby's airway was patent but compromised by mucous and secretions from what we suspected was respiratory syncytial virus (RSV), a viral infection of the lungs and airways of children primarily less than 1 year old. It is a common source of bronchial infection and pneumonia in infants.
Attend to positioning, initiate suctioning, both with a bulb syringe and wall-mounted vacuum suction via a Delee suction device, stimulates baby to breath as well as helps keeps baby's airway clear. Check.
B. As already noted, baby's breathing and oxygenation were poor. Respiratory rate was in the 80s-90s (normal values are in the 40s-50s) and oxygen saturation (a less than completely accurate measure of tissue perfusion, i.e., how much life-sustaining oxygen is getting to the organs and tissues) was approximately 88% (normal is 97%-100%).
Provide supplemental oxygen. But for a small infant this isn't the easiest intervention. Nasal cannulas and infant oxygen masks are notoriously less than effective. What is needed is an environment completely rich in oxygen, like in an incubator. We don't have this technology in the ER.
Thanks to our Respiratory Therapist (RT), a infant "hood"--a plastic dome, sort of like an astronaut's helmet, with a cut-out for the neck and sliding access panels--was placed over the baby's head as she laid on the pad of the baby warmer, a special device for infants that is no more than a treatment table with a warming light over it and oxygen tanks and suction canisters attached.
Check.
C. The baby's heart rate was in the 180s (normal is 130-140s). Increased heart rate is, in part, a compensatory response to poor oxygenation and dehydration, a condition that increases when babies are sick. If tissues aren't receiving enough oxygen, the body will attempt to increase oxygen supply by passing more blood through the tissues. To do this, the brain stimulates the heart to beat faster. However, when the heart beats faster, more oxygen is consumed by the heart and the muscle begins to tire. And so, a vicious cycle ensues.
If intervention is too slow or inadequate, baby will literally wear herself out. With a heart rate of 180 and oxygenation of 88%, we were already "behind the eight ball" as a popular expression goes.
Supplemental oxygen is a good first step. Next, intravenous fluid boluses to increase the volume of fluid in the blood stream to off-set the effects of dehydration. Intravenous access also allows for easier drug administration.
Thanks to a Family Birth Center nurse, IV access was achieved within the hour of baby's arrival in the ER. Why didn't I do it? For the same reason I don't change the oil in my car...I can do it, but there are people who specialize in this sort of thing. Part of being an ER nurse is the wisdom and foresight for judicious use of resources. FBC was my resource in this case!
Circulation, check.
There is a D as well (ABC,D): Differential Diagnosis.
We suspected RSV but other conditions could cause what we were seeing. Cold-stress is another possibility. Hypothermia forces a baby to increase heart rate and breathing in order to maintain body temperature. Assessment: In fact, baby's initial rectal temp was 95.4 (normal is, of course, 98.6). Intervention: warm baby up. Using the baby warmer is standard. Warmed IV fluids helps. A special infant chemical-warming pad was also used.
Hypoglycemia is also suspected. Low blood sugar reduces metabolism; reduced metabolism decreases body temperature. No fuel for the fire. Assessment: Baby's heel stick blood sugar was 66, normal. Intervention: IV glucose (if necessary).
Check.
For three hours, we (RT, the FBC nurse, and I) attempted to improve baby's breathing, all of us, baby included, suffering through pronounced and prolonged apneic periods during which baby would stop breathing for up to 7 and 8 seconds at a time. I began to wonder from which episode baby would not recover, requiring a resuscitation effort, the survival rate of which is low.
I don't pray, but I have wishes. I wished that it wouldn't come to this.
Eventually, we transported baby via helicopter to a pediatric emergency room and, I assume, NICU (Newborn Intensive Care Unit) at the nearest large hospital. Although I haven't heard, I assumed baby's prognosis is good.
I would be lying if I denied being relieved and happy that baby was gone and out of my ER. I know my nursing limits. Baby's condition was pushing and, in some ways, surpassing them. I'm not embarrassed to admit it.
We often joke among ourselves concerning triage that there are two categories of infants: good babies and bad babies. Nearly 97-99% of babies brought in by parents are of the former category. Most of these suffer from what we call PPP, piss-poor parenting. It's the other 1% or so that scare me.
My "bad baby" experience reminds me that, no matter what my demons, I need to be ever-mindful of my skills and abilities and the limits to these, and to swallow my pride when it comes to the health of a infant. I hope I did and will always do the right thing.
Yesterday, I accepted the care of a 53 day old female with respiratory distress. There is nothing more frightening to me as a parent and as an ER nurse than a baby that can't breathe or isn't breathing well.
As a parent, I recall a time when my infant son choked on a small cracker, and how the minutes he did not seem to be able to breathe shortened my life, I'm convinced, by years.
I recall, too, the several times I have had to resuscitate him when he did not regain spontaneous breathing after having seizures.
There is nothing worse than a child who will not breathe!
As a nurse, flashes of parents' hopes for their child as I care for him or her rush through my head and I realize that I am somewhat the keeper of these. I also become entrusted by the parents as easily, it seems, as one would entrust their poorly running car to a mechanic. I do not want this responsibility, but by virtue of my training and career, I have tacitly agreed to accept it.
Okay. ABCs.
A. Baby's airway was patent but compromised by mucous and secretions from what we suspected was respiratory syncytial virus (RSV), a viral infection of the lungs and airways of children primarily less than 1 year old. It is a common source of bronchial infection and pneumonia in infants.
Attend to positioning, initiate suctioning, both with a bulb syringe and wall-mounted vacuum suction via a Delee suction device, stimulates baby to breath as well as helps keeps baby's airway clear. Check.
B. As already noted, baby's breathing and oxygenation were poor. Respiratory rate was in the 80s-90s (normal values are in the 40s-50s) and oxygen saturation (a less than completely accurate measure of tissue perfusion, i.e., how much life-sustaining oxygen is getting to the organs and tissues) was approximately 88% (normal is 97%-100%).
Provide supplemental oxygen. But for a small infant this isn't the easiest intervention. Nasal cannulas and infant oxygen masks are notoriously less than effective. What is needed is an environment completely rich in oxygen, like in an incubator. We don't have this technology in the ER.
Thanks to our Respiratory Therapist (RT), a infant "hood"--a plastic dome, sort of like an astronaut's helmet, with a cut-out for the neck and sliding access panels--was placed over the baby's head as she laid on the pad of the baby warmer, a special device for infants that is no more than a treatment table with a warming light over it and oxygen tanks and suction canisters attached.
Check.
C. The baby's heart rate was in the 180s (normal is 130-140s). Increased heart rate is, in part, a compensatory response to poor oxygenation and dehydration, a condition that increases when babies are sick. If tissues aren't receiving enough oxygen, the body will attempt to increase oxygen supply by passing more blood through the tissues. To do this, the brain stimulates the heart to beat faster. However, when the heart beats faster, more oxygen is consumed by the heart and the muscle begins to tire. And so, a vicious cycle ensues.
If intervention is too slow or inadequate, baby will literally wear herself out. With a heart rate of 180 and oxygenation of 88%, we were already "behind the eight ball" as a popular expression goes.
Supplemental oxygen is a good first step. Next, intravenous fluid boluses to increase the volume of fluid in the blood stream to off-set the effects of dehydration. Intravenous access also allows for easier drug administration.
Thanks to a Family Birth Center nurse, IV access was achieved within the hour of baby's arrival in the ER. Why didn't I do it? For the same reason I don't change the oil in my car...I can do it, but there are people who specialize in this sort of thing. Part of being an ER nurse is the wisdom and foresight for judicious use of resources. FBC was my resource in this case!
Circulation, check.
There is a D as well (ABC,D): Differential Diagnosis.
We suspected RSV but other conditions could cause what we were seeing. Cold-stress is another possibility. Hypothermia forces a baby to increase heart rate and breathing in order to maintain body temperature. Assessment: In fact, baby's initial rectal temp was 95.4 (normal is, of course, 98.6). Intervention: warm baby up. Using the baby warmer is standard. Warmed IV fluids helps. A special infant chemical-warming pad was also used.
Hypoglycemia is also suspected. Low blood sugar reduces metabolism; reduced metabolism decreases body temperature. No fuel for the fire. Assessment: Baby's heel stick blood sugar was 66, normal. Intervention: IV glucose (if necessary).
Check.
For three hours, we (RT, the FBC nurse, and I) attempted to improve baby's breathing, all of us, baby included, suffering through pronounced and prolonged apneic periods during which baby would stop breathing for up to 7 and 8 seconds at a time. I began to wonder from which episode baby would not recover, requiring a resuscitation effort, the survival rate of which is low.
I don't pray, but I have wishes. I wished that it wouldn't come to this.
Eventually, we transported baby via helicopter to a pediatric emergency room and, I assume, NICU (Newborn Intensive Care Unit) at the nearest large hospital. Although I haven't heard, I assumed baby's prognosis is good.
I would be lying if I denied being relieved and happy that baby was gone and out of my ER. I know my nursing limits. Baby's condition was pushing and, in some ways, surpassing them. I'm not embarrassed to admit it.
We often joke among ourselves concerning triage that there are two categories of infants: good babies and bad babies. Nearly 97-99% of babies brought in by parents are of the former category. Most of these suffer from what we call PPP, piss-poor parenting. It's the other 1% or so that scare me.
My "bad baby" experience reminds me that, no matter what my demons, I need to be ever-mindful of my skills and abilities and the limits to these, and to swallow my pride when it comes to the health of a infant. I hope I did and will always do the right thing.
Wednesday, January 23, 2008
Health Care Rights (and Wrongs)
Is health care a right? Should everyone in our society have access to health care? Should this access be free? Equal? Or, should it be based upon need, or an individual's ability to pay, or some other category of restriction (e.g., the relative contributions people make to society)?
These are the fundamental questions about health care that we, as a society, have not yet fully addressed. Currently, our health care system functions upon a sickly jumble of half-answers.
It is easy to say that everyone has a "right" to health care, but very few absolute rights exist. Most rights are accorded with exceptions or with responsibilities and obligations placed upon the recipient. (More about obligations and responsibilities another time.)
What are the exceptions to an individual's right to health care? In our society, most exceptions concern the nature and extent of care one can expect.
By virtue of EMTALA, all individuals regardless of ability to pay have a right (see entry of 9/3/07) to a medical screening in an emergency room of a facility that participates in the federally-funded programs of Medicare and Medicaid to determine whether or not s/he is experiencing an emergent condition requiring treatment and/or stabilization and transfer. However, one does not have a right to demand certain treatments or interventions, even if another person may receive these.
In essence, one has a right to treatment for emergencies, but one does not have a right to an MRI for a headache, or a bone scan for "brittle bones," or a heart/lung transplant for organ failure.
Just as one has a right to free speech, one cannot utilize this right wherever and however one wishes. There are restrictions and exceptions.
In the emergency room, what is prudent and customary care for the condition a patient is experiencing and not simply the patient's ideas and desires or even their ability to pay, determines the sort of care they receive. It is the right of the patient to have what is prudent and customary (sometimes called the "standard of care").
But this is not a right transferable to the private sphere of health care. Just because one has a right to such treatment in the ER doesn't mean they have the same rights at the local Family Medical Clinic, or Dr. Joe's, or even at for-profit, privatized hospitals. These services can be exceptions to the right of health care.
In fact, one of the reasons ERs are often saturated with individuals who are un- or underinsured is because physicians and other clinicians in private practice aren't obligated to fulfill an individual's right to health care. Many private practice physicians only accept patients on Medicaid as a small percentage of their overall clientele, and virtually none accept uninsured patients unless they have cash up front. This is sometimes referred to as The American Way.
What this effects is a two-tiered (actually, multi-tiered) system of health care in which privately insured individuals and those with retirement-age or disability-qualifying Medicare can usually access private health care, while poorer individuals who can't afford private insurance or don't work at jobs that are required to provide it (e.g., part-time, seasonal, small businesses, etc.) must rely on Medicaid or no insurance at all.
These latter individuals are those who the New York Times apparently has a problem with gumming up the ERs. Where else are they to go?
If health care is a right with exceptions and restrictions, then these sorts of problems are going to acutely inconvenience even those at the top of the system. However, I suspect these problems inconvenience those at the bottom more often, in fact, chronically.
Inject for-profit motives of private insurance companies, and these problems multiple precipitously. The system, the entire system, is in need of an overhaul.
These are the fundamental questions about health care that we, as a society, have not yet fully addressed. Currently, our health care system functions upon a sickly jumble of half-answers.
It is easy to say that everyone has a "right" to health care, but very few absolute rights exist. Most rights are accorded with exceptions or with responsibilities and obligations placed upon the recipient. (More about obligations and responsibilities another time.)
What are the exceptions to an individual's right to health care? In our society, most exceptions concern the nature and extent of care one can expect.
By virtue of EMTALA, all individuals regardless of ability to pay have a right (see entry of 9/3/07) to a medical screening in an emergency room of a facility that participates in the federally-funded programs of Medicare and Medicaid to determine whether or not s/he is experiencing an emergent condition requiring treatment and/or stabilization and transfer. However, one does not have a right to demand certain treatments or interventions, even if another person may receive these.
In essence, one has a right to treatment for emergencies, but one does not have a right to an MRI for a headache, or a bone scan for "brittle bones," or a heart/lung transplant for organ failure.
Just as one has a right to free speech, one cannot utilize this right wherever and however one wishes. There are restrictions and exceptions.
In the emergency room, what is prudent and customary care for the condition a patient is experiencing and not simply the patient's ideas and desires or even their ability to pay, determines the sort of care they receive. It is the right of the patient to have what is prudent and customary (sometimes called the "standard of care").
But this is not a right transferable to the private sphere of health care. Just because one has a right to such treatment in the ER doesn't mean they have the same rights at the local Family Medical Clinic, or Dr. Joe's, or even at for-profit, privatized hospitals. These services can be exceptions to the right of health care.
In fact, one of the reasons ERs are often saturated with individuals who are un- or underinsured is because physicians and other clinicians in private practice aren't obligated to fulfill an individual's right to health care. Many private practice physicians only accept patients on Medicaid as a small percentage of their overall clientele, and virtually none accept uninsured patients unless they have cash up front. This is sometimes referred to as The American Way.
What this effects is a two-tiered (actually, multi-tiered) system of health care in which privately insured individuals and those with retirement-age or disability-qualifying Medicare can usually access private health care, while poorer individuals who can't afford private insurance or don't work at jobs that are required to provide it (e.g., part-time, seasonal, small businesses, etc.) must rely on Medicaid or no insurance at all.
These latter individuals are those who the New York Times apparently has a problem with gumming up the ERs. Where else are they to go?
If health care is a right with exceptions and restrictions, then these sorts of problems are going to acutely inconvenience even those at the top of the system. However, I suspect these problems inconvenience those at the bottom more often, in fact, chronically.
Inject for-profit motives of private insurance companies, and these problems multiple precipitously. The system, the entire system, is in need of an overhaul.
Tuesday, January 22, 2008
Roe V. Wade V. Bush
On this day in 1973, the supreme court issued a ruling that stated first trimester elective abortions were indeed legal.
On this day in 2001, President G.W. Bush signed an a "memorandum reinstating full abortion restrictions on U.S. overseas aid" (NYTimes). In other words, according to Bush, abortions were not permitted in countries receiving U.S. aid.
What was I saying about inequality when it comes to the U.S.-style "health" care?
On this day in 2001, President G.W. Bush signed an a "memorandum reinstating full abortion restrictions on U.S. overseas aid" (NYTimes). In other words, according to Bush, abortions were not permitted in countries receiving U.S. aid.
What was I saying about inequality when it comes to the U.S.-style "health" care?
What's in a Name (of a Disease)?
http://www.nytimes.com/2008/01/22/health/22dise.html?th&emc=th
Apparently, much more than the disease itself. Although I am not so sure it's a good thing to have a disease named after you, I am sure it's better than being named after a disease.
And I have not done any research on the issue, but I am sure we could find in the history of medical research and development plenty of instances in which what we know now was, in part, generated by nefarious activities of clinicians and scientists. Some of these were members of the Nazi party; some were American scientists and doctors.
The institution of medicine is not immune to the same racism and sexism that plagues society in general (no pun intended), and often this is seen in the "naming" of conditions, procedures, or remedies.
Even one of the most honorable of health-related issues is subject to this: pregnancy and childbirth.
The EDC, which so many confuse for "estimated date of conception," actually is the acronym for "Estimated Date of Confinement." In other words, that time at which the baby will likely be born and the mother will be "confined" to a hospital bed for a week. Now, we know that this rarely happens any longer, that most new mom's go home within a day or two of an uncomplicated birth. But the term persists.
With multiple miscarriages, a woman hopeful of bringing a fetus to term may be labeled an "habitual aborter"! And with each miscarriage, unless there is a known cause, the failure of a conceived pregnancy is said to be a "blighted ovum". In other words, it's the woman's fault, when in fact there is no reason to suspect the ova over the sperm. But a male-dominated medical institution would hardly want to point fingers at themselves and their kind.
What's in a name? A name. But a load of other things that may bother people.
I hold to my original statement, and I'm glad my name isn't Anna Plastic Tumor.
Apparently, much more than the disease itself. Although I am not so sure it's a good thing to have a disease named after you, I am sure it's better than being named after a disease.
And I have not done any research on the issue, but I am sure we could find in the history of medical research and development plenty of instances in which what we know now was, in part, generated by nefarious activities of clinicians and scientists. Some of these were members of the Nazi party; some were American scientists and doctors.
The institution of medicine is not immune to the same racism and sexism that plagues society in general (no pun intended), and often this is seen in the "naming" of conditions, procedures, or remedies.
Even one of the most honorable of health-related issues is subject to this: pregnancy and childbirth.
The EDC, which so many confuse for "estimated date of conception," actually is the acronym for "Estimated Date of Confinement." In other words, that time at which the baby will likely be born and the mother will be "confined" to a hospital bed for a week. Now, we know that this rarely happens any longer, that most new mom's go home within a day or two of an uncomplicated birth. But the term persists.
With multiple miscarriages, a woman hopeful of bringing a fetus to term may be labeled an "habitual aborter"! And with each miscarriage, unless there is a known cause, the failure of a conceived pregnancy is said to be a "blighted ovum". In other words, it's the woman's fault, when in fact there is no reason to suspect the ova over the sperm. But a male-dominated medical institution would hardly want to point fingers at themselves and their kind.
What's in a name? A name. But a load of other things that may bother people.
I hold to my original statement, and I'm glad my name isn't Anna Plastic Tumor.
Saturday, January 19, 2008
Waiting for Goddarn Doctor (Part I)
http://www.nytimes.com/2008/01/19/opinion/19sat3.html?th&emc=th
Whereas, in my opinion, the New York Times is right-on about the negative effects of two-tiered health care coverage--that emergency room wait times have increased thereby decreasing the speed with which the sickest receive necessary treatment--I disagree with the slant of the editorial, revealed in the first sentence, that these negative effects are mostly a problem because they inconvenience those who are on the top tier.
Let's face it, "insurance" is an immoral business. (It's called "protection" in the world of organized crime.) Corporations and individuals reaping huge profits from other individuals who fear illness and injury and the catastrophic costs associated with treatment. These same insurance companies more often than not hedge their investment by accepting only the healthiest clients or at least those who have the most ability to pay premiums, only to eventually deny claims for reimbursement at every turn until such a time that someone, often the court, makes them pay.
It is time for our society to eliminate the ability of a few to profit from the fear of illness or injury of the many. A single-payer, government-regulated system is the answer.
Whereas, in my opinion, the New York Times is right-on about the negative effects of two-tiered health care coverage--that emergency room wait times have increased thereby decreasing the speed with which the sickest receive necessary treatment--I disagree with the slant of the editorial, revealed in the first sentence, that these negative effects are mostly a problem because they inconvenience those who are on the top tier.
Let's face it, "insurance" is an immoral business. (It's called "protection" in the world of organized crime.) Corporations and individuals reaping huge profits from other individuals who fear illness and injury and the catastrophic costs associated with treatment. These same insurance companies more often than not hedge their investment by accepting only the healthiest clients or at least those who have the most ability to pay premiums, only to eventually deny claims for reimbursement at every turn until such a time that someone, often the court, makes them pay.
It is time for our society to eliminate the ability of a few to profit from the fear of illness or injury of the many. A single-payer, government-regulated system is the answer.
Wednesday, January 16, 2008
Dispatch Interpretations and Other EMS Debacles
Emergency Medical Service (EMS) is an important component of any community's health care system. 911 dispatchers, EMTs (Emergency Medical Technicians) and paramedics, extrication teams, etc. are the individuals who, paid or otherwise, are responsible for ensuring that your medical "emergency" is taken care of.
Why the quotes? Because "emergency" is a euphemism for whatever a 911-caller says is an emergency. It is also whatever the dispatcher thinks is an emergency. Tremendous variation exists.
It begins with the interaction between caller and "dispatch," a group of EMS individuals with limited or no medical training who answer 911 calls--usually answering with the phrase "Police and fire." Dispatchers use latitude in interpreting the emergency nature of any particular call.
In our community there are five response levels for medical emergencies based upon the nature and/or severity of the emergency. These levels indicate to EMTs, etc., what sort of problem the caller is experiencing or witnessing, how serious it may be, and what sort of personnel and equipment might be necessary for a successful intervention.
An "alpha" response is a non-immediate transport of a patient for a minor problem or illness, or the transfer of a stable patient from one medical facility (e.g., nursing home, hospital, etc.) to another.
A "bravo" response is more serious and emergent. It is used for motor vehicle accidents in which unknown injuries may have occurred or for patients with undisclosed medical emergencies, whether injury or illness.
"Charlie" designates a serious emergent illness that is potentially life-threatening (e.g., chest pain, shortness of breath, severe allergic reaction).
A "delta" response may indicate a serious accident in which there are known injuries, a serious traffic accident requiring extrication of patients from vehicles, and/or a serious medical problem like uncontrolled bleeding, etc. EMT and/or paramedic assistance is necessary as soon as possible.
"Echo" response is reserved for problems requiring near-instantaneous attention, like an on-going resuscitation attempt by by-standers or the need for CPR. This response usually means someone is as close to being dead, either because of illness or injury, either this side or that side of death, as they can possibly be. Needless to say, echo responses don't usually result in successful interventions.
However, the amount of interpretation dispatchers employ in translating 911 calls into responses varies.
Some examples. Recently, four patients were brought to the ER by an out-of-area ambulance after it had been dispatched to a rollover accident. Initially, all of the individuals were assessed by EMTs and refused transport. After the ambulance had returned to its station, however, a second call went out for EMS response to the the same accident. Apparently, the "victims" realized they didn't have a ride home!
A woman calls 911 because her husband is bleeding. The woman, an ICU nurse, says to dispatch, "We need an ambulance quick! My husband's cut his arm and is bleeding from an artery." Serious? Perhaps...probably. But here is how it got called out:
"EMT Ambulance, Echo response for a hemorrhage, 41 year male, attempted suicide!"
Where that last part came from, who knows? The man had been working with a metal range hood that fell on him. Clearly, what is interpreted as an emergency, and what are the circumstances of the emergency, are as much affected by who makes the 911 call as they are by the 911 dispatcher who answers.
Why the quotes? Because "emergency" is a euphemism for whatever a 911-caller says is an emergency. It is also whatever the dispatcher thinks is an emergency. Tremendous variation exists.
It begins with the interaction between caller and "dispatch," a group of EMS individuals with limited or no medical training who answer 911 calls--usually answering with the phrase "Police and fire." Dispatchers use latitude in interpreting the emergency nature of any particular call.
In our community there are five response levels for medical emergencies based upon the nature and/or severity of the emergency. These levels indicate to EMTs, etc., what sort of problem the caller is experiencing or witnessing, how serious it may be, and what sort of personnel and equipment might be necessary for a successful intervention.
An "alpha" response is a non-immediate transport of a patient for a minor problem or illness, or the transfer of a stable patient from one medical facility (e.g., nursing home, hospital, etc.) to another.
A "bravo" response is more serious and emergent. It is used for motor vehicle accidents in which unknown injuries may have occurred or for patients with undisclosed medical emergencies, whether injury or illness.
"Charlie" designates a serious emergent illness that is potentially life-threatening (e.g., chest pain, shortness of breath, severe allergic reaction).
A "delta" response may indicate a serious accident in which there are known injuries, a serious traffic accident requiring extrication of patients from vehicles, and/or a serious medical problem like uncontrolled bleeding, etc. EMT and/or paramedic assistance is necessary as soon as possible.
"Echo" response is reserved for problems requiring near-instantaneous attention, like an on-going resuscitation attempt by by-standers or the need for CPR. This response usually means someone is as close to being dead, either because of illness or injury, either this side or that side of death, as they can possibly be. Needless to say, echo responses don't usually result in successful interventions.
However, the amount of interpretation dispatchers employ in translating 911 calls into responses varies.
Some examples. Recently, four patients were brought to the ER by an out-of-area ambulance after it had been dispatched to a rollover accident. Initially, all of the individuals were assessed by EMTs and refused transport. After the ambulance had returned to its station, however, a second call went out for EMS response to the the same accident. Apparently, the "victims" realized they didn't have a ride home!
A woman calls 911 because her husband is bleeding. The woman, an ICU nurse, says to dispatch, "We need an ambulance quick! My husband's cut his arm and is bleeding from an artery." Serious? Perhaps...probably. But here is how it got called out:
"EMT Ambulance, Echo response for a hemorrhage, 41 year male, attempted suicide!"
Where that last part came from, who knows? The man had been working with a metal range hood that fell on him. Clearly, what is interpreted as an emergency, and what are the circumstances of the emergency, are as much affected by who makes the 911 call as they are by the 911 dispatcher who answers.
Tuesday, January 15, 2008
The Danger of Driving on Cell Phones
A picture is worth a thousand warnings. Please do not talk on you cell phone while driving. As the popular bumper sticker in Seattle says, "Hang Up and Drive!"
Monday, December 31, 2007
On the Eve of Resolution
I could not let this year pass without a few simple comments about health and fitness.
Like many people I know in the northern hemisphere, winter brings with it a time of weight gain and exercise laxness. Throw in back-to-back holidays characterized by rich foods, cakes, pies and candies, and excessive alcohol consumption, and many of us find ourselves relaxing our belts, dreaming of diets, and redefining flab as love handles.
What did Rene say: I eat too much; therefore, I am fat.
Having a few extra pounds in colder climates might seem like prudent insulation. But the stress of trudging through deep snow and trudging through the deep stress of Xmas and New Years can put a lot of strain on the cardiovascular system. A few extra pounds doesn't help.
And I am not pointing fingers. I include myself in the category of those who may have indulged and bugled too much whilst exercising too little. In fact, this trend didn't start with winter or the holidays. I have been slowly gaining weight since my all-time adult low weight of about two and a half years ago.
What happened?
Well, I got happy. No joke. I was at that all-time adult low weight because I was experiencing a lot stress about a family member in the midst of medical crisis. I wasn't eating well or enough, and I was exercising incessantly in an attempt to preoccupy my racing mind and reduce the negative effects of stress. Needless to say, I wheedled down.
Then almost two years ago, the crisis seemed to be (relatively) fading, the stress began to lift, and I became involved in a very happy period of my life. Needless to also say, my relaxation wasn't only mental; my waist relaxed as well.
In the year 2008, therefore, I hope to reclaim a diet and exercise ritual that is healthy, safe, and effective. By the latter I don't simply mean in terms of losing weight, but instead, feeling and being healthy. I owe it to myself, to my family, and to my community. Happiness should beget healthiness, not hedonism.
And so, bring on the New Year!
Like many people I know in the northern hemisphere, winter brings with it a time of weight gain and exercise laxness. Throw in back-to-back holidays characterized by rich foods, cakes, pies and candies, and excessive alcohol consumption, and many of us find ourselves relaxing our belts, dreaming of diets, and redefining flab as love handles.
What did Rene say: I eat too much; therefore, I am fat.
Having a few extra pounds in colder climates might seem like prudent insulation. But the stress of trudging through deep snow and trudging through the deep stress of Xmas and New Years can put a lot of strain on the cardiovascular system. A few extra pounds doesn't help.
And I am not pointing fingers. I include myself in the category of those who may have indulged and bugled too much whilst exercising too little. In fact, this trend didn't start with winter or the holidays. I have been slowly gaining weight since my all-time adult low weight of about two and a half years ago.
What happened?
Well, I got happy. No joke. I was at that all-time adult low weight because I was experiencing a lot stress about a family member in the midst of medical crisis. I wasn't eating well or enough, and I was exercising incessantly in an attempt to preoccupy my racing mind and reduce the negative effects of stress. Needless to say, I wheedled down.
Then almost two years ago, the crisis seemed to be (relatively) fading, the stress began to lift, and I became involved in a very happy period of my life. Needless to also say, my relaxation wasn't only mental; my waist relaxed as well.
In the year 2008, therefore, I hope to reclaim a diet and exercise ritual that is healthy, safe, and effective. By the latter I don't simply mean in terms of losing weight, but instead, feeling and being healthy. I owe it to myself, to my family, and to my community. Happiness should beget healthiness, not hedonism.
And so, bring on the New Year!
Friday, December 28, 2007
Never Put New Nurses into Old Nursing Skins
I received an e-mail from a friend today that informed me she planned to enrol in nursing school. Knowing her, I think she will enjoy the challenges and diverse employment opportunities the career of nursing presents. Knowing her, also, I'm not sure she'll enjoy nursing school. I didn't.
Needless to say, I sometimes feel guilty when friends of mine decide to go into nursing. I have encouraged at least four friends to leave their previous professions and become nurses via, of course, nursing school. (The friend who recently e-mailed is not among them.) I feel so strongly about the personal and societal benefits of more people being nurses that I don't mind recommending the career to them. However, knowing they have to go through nursing school to get there fills me with a bit of remorse.
It is not that I don't think they'll be able to succeed in nursing school--I have smart friends. It is that I know such a pursuit will aggravate, frustrate, and probably disappoint them. Oh, they'll graduate and come out as nurses, but they'll do a lot in the interim that has little to do with being a nurse. Really.
Like most other associates and bachelors degree programs and most professional-technical education programs, nursing school is very much about busy work and tedious conformity to standards that have little to do with nursing and what nurses actually do. Instead, nursing school is mostly about...well, nursing school. It is about doing the work, making the grade, and passing classes, the ultimate goal of which is to get the degree. In short, a rather underwhelming experience.
One would think nursing school is about learning the professional skills and culture of nursing. That would make sense. But there is a disconnect between what nurses do and the organizations in which they do it and the experience of the nursing student. I don't think this has always been the case, but it is prevalent now.
I went to nursing school later in life, in my 30s, after having already completed a bachelors and masters degree in an unrelated discipline, and having worked in several professional pursuits. I knew how to get through nursing school, and I had enough sense to know that working as a nursing student wasn't going to be like working as a nurse.
But many of my fellow nursing school students were in their late teens, traditional students by college standards. Some of them seemed to chose the nursing program as as just another college major, similar to accounting or English or biology. There did not seem to be anything about their lives that propelled them toward nursing or encouraged them to become nurses. They had gone to college because that is what you do after high school. It was an expectation.
Choosing nursing probably felt good to them and others probably responded to their choice with support and encouragement. But did they know what they were getting into? Did nursing school prepare them for what they would be doing as nurses?
As a nurse, I have likewise had the opportunity to precept nursing students and orient new nurses. I have had nursing students who fainted at the site of blood, got sick to their stomachs because of the smell of feces or vomit, or couldn't handle the look of a surgical site or stand poking a patient with a needle. Wouldn't they have made better accountants? How come they didn't know this?
I've also had students and sometimes new nurses who couldn't reason what amount of medicine to give a patient when the order was for 1 milligram but the medicine vial contained 2 milligrams per milliliter. Clearly they shouldn't have been nurses, or shouldn't have passed nursing school anyway.
When precepting or orienting new nurses I try to communicate a single idea: that being a good nurse is not about doing it the way they told you to do it in nursing school, but to develop your own method and rhythm and style and become the nurse you want to be, not the nurse they tried to cookie cut.
So, I am glad that my friend is going into nursing. I suppose I've written this both as encouragement to her and also a warning. Nursing school is not about being a nurse. Get through it, learn the theory, the methods, and perform the skills the way they tell you to. And then, after graduation, forget it all and become the nurse you want to be.
That's what I did.
Needless to say, I sometimes feel guilty when friends of mine decide to go into nursing. I have encouraged at least four friends to leave their previous professions and become nurses via, of course, nursing school. (The friend who recently e-mailed is not among them.) I feel so strongly about the personal and societal benefits of more people being nurses that I don't mind recommending the career to them. However, knowing they have to go through nursing school to get there fills me with a bit of remorse.
It is not that I don't think they'll be able to succeed in nursing school--I have smart friends. It is that I know such a pursuit will aggravate, frustrate, and probably disappoint them. Oh, they'll graduate and come out as nurses, but they'll do a lot in the interim that has little to do with being a nurse. Really.
Like most other associates and bachelors degree programs and most professional-technical education programs, nursing school is very much about busy work and tedious conformity to standards that have little to do with nursing and what nurses actually do. Instead, nursing school is mostly about...well, nursing school. It is about doing the work, making the grade, and passing classes, the ultimate goal of which is to get the degree. In short, a rather underwhelming experience.
One would think nursing school is about learning the professional skills and culture of nursing. That would make sense. But there is a disconnect between what nurses do and the organizations in which they do it and the experience of the nursing student. I don't think this has always been the case, but it is prevalent now.
I went to nursing school later in life, in my 30s, after having already completed a bachelors and masters degree in an unrelated discipline, and having worked in several professional pursuits. I knew how to get through nursing school, and I had enough sense to know that working as a nursing student wasn't going to be like working as a nurse.
But many of my fellow nursing school students were in their late teens, traditional students by college standards. Some of them seemed to chose the nursing program as as just another college major, similar to accounting or English or biology. There did not seem to be anything about their lives that propelled them toward nursing or encouraged them to become nurses. They had gone to college because that is what you do after high school. It was an expectation.
Choosing nursing probably felt good to them and others probably responded to their choice with support and encouragement. But did they know what they were getting into? Did nursing school prepare them for what they would be doing as nurses?
As a nurse, I have likewise had the opportunity to precept nursing students and orient new nurses. I have had nursing students who fainted at the site of blood, got sick to their stomachs because of the smell of feces or vomit, or couldn't handle the look of a surgical site or stand poking a patient with a needle. Wouldn't they have made better accountants? How come they didn't know this?
I've also had students and sometimes new nurses who couldn't reason what amount of medicine to give a patient when the order was for 1 milligram but the medicine vial contained 2 milligrams per milliliter. Clearly they shouldn't have been nurses, or shouldn't have passed nursing school anyway.
When precepting or orienting new nurses I try to communicate a single idea: that being a good nurse is not about doing it the way they told you to do it in nursing school, but to develop your own method and rhythm and style and become the nurse you want to be, not the nurse they tried to cookie cut.
So, I am glad that my friend is going into nursing. I suppose I've written this both as encouragement to her and also a warning. Nursing school is not about being a nurse. Get through it, learn the theory, the methods, and perform the skills the way they tell you to. And then, after graduation, forget it all and become the nurse you want to be.
That's what I did.
Wednesday, December 26, 2007
A Chatty Post-Holiday Entry
Okay. The holiday is over. Most of mine was spent, you guessed it, in the ER taking care of every nebulous, insignificant, and ridiculous complaint that this community could throw our way.
*** A sore throat that you've had for two and a half weeks is an emergency on Christmas Day, why?
*** A 9-month old's diaper rash is an emergency at 2 a.m. Christmas Eve morning, why?
Why?
Because in this community, we were the only health care available on the Eve and Christmas Day. Doc's offices aren't open; student health isn't open; the urgent care clinics aren't open. We were it.
To be fair, some patients did have legitimate complaints. I started my stretch by being called in to work on the weekend when two head-on accidents with passenger ejections occurred at the same time. The lone ER nurse (who was that because of double sick calls) was desperate for help. I thought I'd give her an hour or so of my time; I ended up giving her 4 hours.
Her patient ate a cement embankment after being thrown from the passenger window of a pick-up (wasn't wearing a seat belt!) and was found by EMTs face down in a pool of congealed blood. Broke nearly every bone in her face except her jaw, had a transverse skull fracture, dislocated her elbow, and fractured her tibia. We stablizied her and then had to admit her because the inclimate weather didn't allow for either air or ground transport to a higher level trauma center. Last I heard, she was still alive at Harborview in Seattle. Lucky her, maybe.
My patient was a 13 year old who was thrown from the middle seat of a minivan despite the fact that he was wearing a seat belt. The sliding door had been ripped off, which allowed for his ejection. A fractured nose and fractured iliac crest of the pelvis and he had gotten off easy.
And that was it for trauma. The next three days, including Christmas Eve and Day, I heard as many clinic complaints of soar throats, tendonitis, urinary tact infections, etc., as I care to. Good thing we were here for them!
Sure happy I don't work for the New Years and its Eve. Happy, Healthy Holidays to all!
*** A sore throat that you've had for two and a half weeks is an emergency on Christmas Day, why?
*** A 9-month old's diaper rash is an emergency at 2 a.m. Christmas Eve morning, why?
Why?
Because in this community, we were the only health care available on the Eve and Christmas Day. Doc's offices aren't open; student health isn't open; the urgent care clinics aren't open. We were it.
To be fair, some patients did have legitimate complaints. I started my stretch by being called in to work on the weekend when two head-on accidents with passenger ejections occurred at the same time. The lone ER nurse (who was that because of double sick calls) was desperate for help. I thought I'd give her an hour or so of my time; I ended up giving her 4 hours.
Her patient ate a cement embankment after being thrown from the passenger window of a pick-up (wasn't wearing a seat belt!) and was found by EMTs face down in a pool of congealed blood. Broke nearly every bone in her face except her jaw, had a transverse skull fracture, dislocated her elbow, and fractured her tibia. We stablizied her and then had to admit her because the inclimate weather didn't allow for either air or ground transport to a higher level trauma center. Last I heard, she was still alive at Harborview in Seattle. Lucky her, maybe.
My patient was a 13 year old who was thrown from the middle seat of a minivan despite the fact that he was wearing a seat belt. The sliding door had been ripped off, which allowed for his ejection. A fractured nose and fractured iliac crest of the pelvis and he had gotten off easy.
And that was it for trauma. The next three days, including Christmas Eve and Day, I heard as many clinic complaints of soar throats, tendonitis, urinary tact infections, etc., as I care to. Good thing we were here for them!
Sure happy I don't work for the New Years and its Eve. Happy, Healthy Holidays to all!
Friday, December 14, 2007
The Art of Children's Hospital
A friend of mine once surmised that hospitals are depressing because they are generally painted in browns and mauves and don't have any art on the walls. I agree with her.
But hospitals have changed. The one I am sitting in now, a Children's Hospital, is so brightly colored and has so much of all sorts of art that it is hard to tell that it is a hospital at all.
There are giraffe and zebra statues in the halls, giant fish tanks, a choo choo train on tracks in one corridor, and a huge Native American-inspired representation of an Orca, a sculpture measuring approximately 25 feet in length (life-size) and so heavy that it is suspended from the ceiling on thick metal cables. There are rocket ships and stylized balloons and an entire jungle creation in the radiology suites.
The idea, I suppose, is to help children forget they are patients in a hospital, or perhaps, help their visitors forget this. The relative success of the decor could be argued, but at least it is not a drab environment.
For me, however, Children's is a sobering and humbling experience. There is nowhere else I can spend time that makes me feel as fortunate to have the child I have, despite his relative disabilities and chronic illness. No matter how bad things have gotten for him and for us together, when we are here I do not feel as if things for us have been so bad, so depressing.
But it isn't the art or the colors that does this. It is the children in wheelchairs, the horribly disfigured children, the ones without hair, without limbs, with all manner of bodily insult, deprivation, chronic illness, life-threatening illness and injuries, and the sullen and depressed faces of their parents and visitors that helps me realize how good my son's life is and how good our life together is.
I know this is an odd observation, but who doesn't feel at least a little better when they realize they are not the worst off?
But hospitals have changed. The one I am sitting in now, a Children's Hospital, is so brightly colored and has so much of all sorts of art that it is hard to tell that it is a hospital at all.
There are giraffe and zebra statues in the halls, giant fish tanks, a choo choo train on tracks in one corridor, and a huge Native American-inspired representation of an Orca, a sculpture measuring approximately 25 feet in length (life-size) and so heavy that it is suspended from the ceiling on thick metal cables. There are rocket ships and stylized balloons and an entire jungle creation in the radiology suites.
The idea, I suppose, is to help children forget they are patients in a hospital, or perhaps, help their visitors forget this. The relative success of the decor could be argued, but at least it is not a drab environment.
For me, however, Children's is a sobering and humbling experience. There is nowhere else I can spend time that makes me feel as fortunate to have the child I have, despite his relative disabilities and chronic illness. No matter how bad things have gotten for him and for us together, when we are here I do not feel as if things for us have been so bad, so depressing.
But it isn't the art or the colors that does this. It is the children in wheelchairs, the horribly disfigured children, the ones without hair, without limbs, with all manner of bodily insult, deprivation, chronic illness, life-threatening illness and injuries, and the sullen and depressed faces of their parents and visitors that helps me realize how good my son's life is and how good our life together is.
I know this is an odd observation, but who doesn't feel at least a little better when they realize they are not the worst off?
Monday, December 10, 2007
(Why Do) Things Fall Apart
In memory of my friend's brother...
Before studying nursing I wondered why people got sick, why bodies break down and fall apart. I was amazed by how capricious disease and injury seemed to be, and how the effects on the body seemed indiscriminate and sometimes unimaginable.
After studying the structure and function of the body in anatomy (with a cadaver lab) and physiology, and the dysfunction of the body in pathophysiology, I began to wonder how people maintain their health at all, why we all don't just fall down and break apart this very minute.
The complexity of the biological form and the intricacy of its functions amaze me. With all the ways in which the body could break down and with all of its susceptibility to disease and injury, the fact that it has such tenacious integrity places me in awe of it.
When a hammer doesn't work or work effectively it is usually easy to figure out why. A broken or too short handle, broken or too light head. But when a computer doesn't work, diagnosis is a little more difficult. The relative complexity of these tools determines our ability to understand the former easily and the latter with more difficulty.
The body is both and more. Physically, a mechanical, hydraulic system of levers and fulcrums, pumps and pulleys; an electrical, computer-like system of stimuli and currents, algorithms and feedback loops; a chemical system of neurotransmitters and pathways. Metaphysically, the systems and systems' components altogether are greater than simply their sum.
The human body, in health and in illness. Amazing.
Before studying nursing I wondered why people got sick, why bodies break down and fall apart. I was amazed by how capricious disease and injury seemed to be, and how the effects on the body seemed indiscriminate and sometimes unimaginable.
After studying the structure and function of the body in anatomy (with a cadaver lab) and physiology, and the dysfunction of the body in pathophysiology, I began to wonder how people maintain their health at all, why we all don't just fall down and break apart this very minute.
The complexity of the biological form and the intricacy of its functions amaze me. With all the ways in which the body could break down and with all of its susceptibility to disease and injury, the fact that it has such tenacious integrity places me in awe of it.
When a hammer doesn't work or work effectively it is usually easy to figure out why. A broken or too short handle, broken or too light head. But when a computer doesn't work, diagnosis is a little more difficult. The relative complexity of these tools determines our ability to understand the former easily and the latter with more difficulty.
The body is both and more. Physically, a mechanical, hydraulic system of levers and fulcrums, pumps and pulleys; an electrical, computer-like system of stimuli and currents, algorithms and feedback loops; a chemical system of neurotransmitters and pathways. Metaphysically, the systems and systems' components altogether are greater than simply their sum.
The human body, in health and in illness. Amazing.
Saturday, December 8, 2007
Ethics and Nursing Compensation
I am happy to report that the dispute between nurses and the administration of the hospital in which I work mentioned in the previous post has been resolved.
I am doubly happy to report that the administration has decided to eliminate wage disparity among staff nurses, moving all nurses to a single wage scale regardless in which department of the organization they work.
I take a modicum of pride in this resolution because the philosophical commitment to wage equity was the position for which I argued from the beginning of the struggle. The administration has, apparently, changed its organizational mind in order to agree with me (and other nurses who felt the same).
I could be magnanimous and believe that the administration's change of position is wholly based upon its ethical commitment to wage equity, that they have done the right thing because it is right. I could believe that the administration is made up of good people in this fashion.
However, good people or not, no organization does what it does not have to do. No organization risks financial insolvency if it does not have to, not simply so that it can be said to have done the right thing. No. The administration's actions are clearly based upon the fact that financially it could produce wage equity. The money was there; the money was there all along.
So then what is the lesson to learn from this struggle?
The lesson I learned is multi-faceted but simple: Organizations do what they can do in the context of good reasons to do it. What the administration of our hospital needed in order to make the decision it did was a good and compelling reason to do it.
We, the nursing staff, provided that for the administration by demonstrating our collective will to continually advocate for a single wage scale, even if it meant taking our case to the hospital's board of directors and eventually to the public. Both of these intentions were in formulation at the time the announcement of a single and increased wage decision was made.
What the administration did was devote the financial resources it has to avoid the uncharitable position of being called upon by the board of directors to answer for a dissatisfied nursing staff, a possible "don't show up for work today" action, and the negative publicity such would generate in a small town that has the general impression that the hospital is a decent, caring organization.
The other part of the lesson I learned is never doubt yourself or the value of your endeavors when you know that you stand up for a right and good thing. There were times that we could have accepted the mediocre offers made to us, offers that were somewhat generous but did not resolve the issue of wage inequity.
Despite the fact that some of us could have benefited from these offers, we stood up for an ultimate good over immediate gain. We're nurses, after all. We like to take care of ourselves, all of ourselves.
I am doubly happy to report that the administration has decided to eliminate wage disparity among staff nurses, moving all nurses to a single wage scale regardless in which department of the organization they work.
I take a modicum of pride in this resolution because the philosophical commitment to wage equity was the position for which I argued from the beginning of the struggle. The administration has, apparently, changed its organizational mind in order to agree with me (and other nurses who felt the same).
I could be magnanimous and believe that the administration's change of position is wholly based upon its ethical commitment to wage equity, that they have done the right thing because it is right. I could believe that the administration is made up of good people in this fashion.
However, good people or not, no organization does what it does not have to do. No organization risks financial insolvency if it does not have to, not simply so that it can be said to have done the right thing. No. The administration's actions are clearly based upon the fact that financially it could produce wage equity. The money was there; the money was there all along.
So then what is the lesson to learn from this struggle?
The lesson I learned is multi-faceted but simple: Organizations do what they can do in the context of good reasons to do it. What the administration of our hospital needed in order to make the decision it did was a good and compelling reason to do it.
We, the nursing staff, provided that for the administration by demonstrating our collective will to continually advocate for a single wage scale, even if it meant taking our case to the hospital's board of directors and eventually to the public. Both of these intentions were in formulation at the time the announcement of a single and increased wage decision was made.
What the administration did was devote the financial resources it has to avoid the uncharitable position of being called upon by the board of directors to answer for a dissatisfied nursing staff, a possible "don't show up for work today" action, and the negative publicity such would generate in a small town that has the general impression that the hospital is a decent, caring organization.
The other part of the lesson I learned is never doubt yourself or the value of your endeavors when you know that you stand up for a right and good thing. There were times that we could have accepted the mediocre offers made to us, offers that were somewhat generous but did not resolve the issue of wage inequity.
Despite the fact that some of us could have benefited from these offers, we stood up for an ultimate good over immediate gain. We're nurses, after all. We like to take care of ourselves, all of ourselves.
Wednesday, December 5, 2007
Wage Dispute
It is somewhat funny to me that many people think that being a nurse should be in and of itself satisfying. That the generally high esteem in which the public holds us should be reason enough to do the sometimes hard, sometimes gory, sometimes horrible job we do. To be an ER nurse, like being a hospice nurse, seems to double this sentiment.
People watch too much TV.
In fact, and I know this may come as a shock to some people, nurses like to get PAID for what we do. I don't know a single nurse who would work as one unless s/he got paid to do so. Like many workers, nurses may not be paid as much as they would want--no one goes into nursing to get rich--but they work at nursing in (perhaps unrealistic) hope of being paid for their labor what it is truly worth. Given that peoples' lives are often at stake, it seems that what we do should be worth a lot.
Recently, however, the hospital in which I work that employs over a hundred nurses has chosen to give a small minority of those nurses (approximately seven) a 15% wage increase simply because they are "surgery" nurses. There really is no other way to explain it.
The nurses in question have no more education, licensure, or skills than other nurses in the organization; they do not work harder or more; they are required to have fewer skill certifications than ER nurses (1 versus 4); and they do not even do what many other nurses in the organization are required to do: float to other departments, respond to codes, start IVs (the anesthetists or same day center nurses do it) or push medications (again, anesthetists or ICU nurses do it).
The administration's rationale for this unfair compensation increase is that surgery generates a lot of revenue for the hospital and we certainly can't allow the surgery department to close down. Forget the fact that it was not in jeopardy, that surgery nurses were not threatening to leave, and the fact that you can no more run a hospital without medical surgical nurses, same day center nurses, emergency room nurses, recovery nurses, etc.
The result has been that many of the other nurses in the hospital feel as if their labor has been de-valued. They feel that the organization has told them that they are not worth as much. There is foment of unrest and talk of walk outs.
I know the public is not used to the idea that nurses could refuse to work. It seems like patient abandonment. It seems wrong. But nurses who won't work for substandard or unfair wages or nurses who will not work under the stressful conditions of unsafe patient loads are not trying to be hurtful to patients. They are trying to demonstrate to health care organizations that they shouldn't be taken for granted.
I, for one, like being a nurse. But not being a nurse for nothing.
People watch too much TV.
In fact, and I know this may come as a shock to some people, nurses like to get PAID for what we do. I don't know a single nurse who would work as one unless s/he got paid to do so. Like many workers, nurses may not be paid as much as they would want--no one goes into nursing to get rich--but they work at nursing in (perhaps unrealistic) hope of being paid for their labor what it is truly worth. Given that peoples' lives are often at stake, it seems that what we do should be worth a lot.
Recently, however, the hospital in which I work that employs over a hundred nurses has chosen to give a small minority of those nurses (approximately seven) a 15% wage increase simply because they are "surgery" nurses. There really is no other way to explain it.
The nurses in question have no more education, licensure, or skills than other nurses in the organization; they do not work harder or more; they are required to have fewer skill certifications than ER nurses (1 versus 4); and they do not even do what many other nurses in the organization are required to do: float to other departments, respond to codes, start IVs (the anesthetists or same day center nurses do it) or push medications (again, anesthetists or ICU nurses do it).
The administration's rationale for this unfair compensation increase is that surgery generates a lot of revenue for the hospital and we certainly can't allow the surgery department to close down. Forget the fact that it was not in jeopardy, that surgery nurses were not threatening to leave, and the fact that you can no more run a hospital without medical surgical nurses, same day center nurses, emergency room nurses, recovery nurses, etc.
The result has been that many of the other nurses in the hospital feel as if their labor has been de-valued. They feel that the organization has told them that they are not worth as much. There is foment of unrest and talk of walk outs.
I know the public is not used to the idea that nurses could refuse to work. It seems like patient abandonment. It seems wrong. But nurses who won't work for substandard or unfair wages or nurses who will not work under the stressful conditions of unsafe patient loads are not trying to be hurtful to patients. They are trying to demonstrate to health care organizations that they shouldn't be taken for granted.
I, for one, like being a nurse. But not being a nurse for nothing.
Monday, December 3, 2007
Types of Patients VIII: Frequent Flyers
Pardon the rather long absence. Sometimes I have things to share and the time to share them, sometimes not.
+++
Every emergency room has it's FFs (frequent flyers). FFs are individuals who utilize emergency room services over and over again, often for the same complaint, and often for complaints that are dubious at best. FFs become familiar with the ER staff as well as to the ER staff, and their complaints are often well-known and predictable.
Some FFs have psychological problems. Bipolar and Borderline personality disorders are common, as well as various forms of psychosis and schizophrenia. Sadly, some FFs have Munchausen Syndrome, a psychotic disorder in which an individual fakes illness or injury, or intentionally injures him/herself, in order to garnish sympathy and be cared for by others.
Sadder still, some FFs have Munchausen Syndrome By Proxy. These are individuals who encourage their child (usually) or other vulnerable relatives to fake illness or injury, or may intentionally injury these people for the same reasons as above.
Some FFs are drug seekers. (See, Types of Patients III)
FFs are usually on some form of public assistance (e.g., Medicaid) but this is not a hard and fast rule. It is amazing, however, how much paying for one's own care directly or indirectly through insurance tends to discourage frequent flying.
Some FFs, however, have real complaints. Migraine headache sufferers, patients with epilepsy, and patients with chronic diseases that are prone to exacerbation (e.g., emphysema, congestive heart failure, etc.) might classify as FFs. Many of these patients actually require emergency care, and yet, it is sometimes hard to feel good about the sort of "buff and polish" we are often required to apply time after time.
FFs also present the ER staff with a potentially serious dilemma: you've seen the patient what seems like at least a million times, and they always come in with the same complaint, and their complaint today is no different...what do you do?
I would like to say that what you do is the sort of comprehensive physical assessment and medical history as well as examination of the chief complaint like you were seeing this person for the very first time. I'd like to say that these patients' complaints are always taken at face value. I'd like to say that the ER staff takes no shortcuts when it comes to FFs.
There are so many things I'd like to say, if only they were all entirely true.
FF status invites shortcuts. It invites seeing the same thing time and time again simply because nothing new is looked for, and consequently, treating FFs in the same way they have always been treated.
Worse yet, FF status discourages the willing suspension of disbelief. If something novel should come up in the cursory exam and assessment, it is all too easy to ignore it. This is potentially dangerous for the FF and a tremendous liability for the ER staff. Unusual symptoms are unexamined; potentially dangerous problems are ignored because they are not found.
There is no easy answer to these problems other than vigilance. The onus of this solution, however, is almost completely placed on the ER staff's shoulders.
Some of us bear the weight better than others.
+++
Every emergency room has it's FFs (frequent flyers). FFs are individuals who utilize emergency room services over and over again, often for the same complaint, and often for complaints that are dubious at best. FFs become familiar with the ER staff as well as to the ER staff, and their complaints are often well-known and predictable.
Some FFs have psychological problems. Bipolar and Borderline personality disorders are common, as well as various forms of psychosis and schizophrenia. Sadly, some FFs have Munchausen Syndrome, a psychotic disorder in which an individual fakes illness or injury, or intentionally injures him/herself, in order to garnish sympathy and be cared for by others.
Sadder still, some FFs have Munchausen Syndrome By Proxy. These are individuals who encourage their child (usually) or other vulnerable relatives to fake illness or injury, or may intentionally injury these people for the same reasons as above.
Some FFs are drug seekers. (See, Types of Patients III)
FFs are usually on some form of public assistance (e.g., Medicaid) but this is not a hard and fast rule. It is amazing, however, how much paying for one's own care directly or indirectly through insurance tends to discourage frequent flying.
Some FFs, however, have real complaints. Migraine headache sufferers, patients with epilepsy, and patients with chronic diseases that are prone to exacerbation (e.g., emphysema, congestive heart failure, etc.) might classify as FFs. Many of these patients actually require emergency care, and yet, it is sometimes hard to feel good about the sort of "buff and polish" we are often required to apply time after time.
FFs also present the ER staff with a potentially serious dilemma: you've seen the patient what seems like at least a million times, and they always come in with the same complaint, and their complaint today is no different...what do you do?
I would like to say that what you do is the sort of comprehensive physical assessment and medical history as well as examination of the chief complaint like you were seeing this person for the very first time. I'd like to say that these patients' complaints are always taken at face value. I'd like to say that the ER staff takes no shortcuts when it comes to FFs.
There are so many things I'd like to say, if only they were all entirely true.
FF status invites shortcuts. It invites seeing the same thing time and time again simply because nothing new is looked for, and consequently, treating FFs in the same way they have always been treated.
Worse yet, FF status discourages the willing suspension of disbelief. If something novel should come up in the cursory exam and assessment, it is all too easy to ignore it. This is potentially dangerous for the FF and a tremendous liability for the ER staff. Unusual symptoms are unexamined; potentially dangerous problems are ignored because they are not found.
There is no easy answer to these problems other than vigilance. The onus of this solution, however, is almost completely placed on the ER staff's shoulders.
Some of us bear the weight better than others.
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