I don’t do code team

New RN: “I don’t do Code team. I have a medical letter to say I don’t have to”

Me: WTF?!

Excuse me? When did you learn that you hated nursing?

Currently there is a practice among nurses that if there is some aspect of your job you don’t want to do, all you have to do is get a physician to write you a note saying you should not do this activity and you are now medically accommodated to not do this activity, yet retain your job. Now I am a fairly reasonable person – if you can’t sleep at all on days and end up sick all the time because you are sleep deprived and you are putting yourself and others at risk because of your sleep habits, then yeah, I think accommodating you to straight day shift is the right thing to do.

But when you come up with this ‘can’t do code team’ bullshit, well I am going to call BullShit! cause frankly I can’t for the life of me figure out why a code inside the ICU is different from a code outside the ICU.

“Oh, I can’t run!”

Clearly there are very, very few people who can run all the way to a code, stairs and all, however you are saved because we now have a policy that you DO NOT run to a code call. Plus you don’t actually drag the cart up the stairs, we have elevators.

“I can’t push the cart”

Again, WTF!? What happens if your patient needs to be pushed to the OR, or radiology or out to the ward? Can you push the bed with that 200 pound patient in it? Clearly you can and so you can push the crash cart.

“no, really, I can’t push the cart and walk fast”

Seriously? This is the line you are going to take? Cause seriously, if you cannot walk fast and push the crash cart, I am thinking ICU is not for you. Patients code in ICU. A Lot. And each and every one of them needs someone to walk quickly to the crash cart and bring it to their room. That someone could very likely be you. You going to tell me you can’t do this? Then I am going to tell you to get the F outta my ICU.

“The adrenalin makes my _________ (fill in chronic convenient disease here) worse”

So how do you control the adrenalin you get when some jackass cuts you off in traffic and you nearly slide off the road? How you prevent an adrenalin surge when a patient arrests in the ICU and needs to have you participate in the code? What is your adrenalin blunting strategy when the helicopter lands and the team pulls through the door in full resuscitation with compressions, exsanguination and weeping family in their wake?

Code team and emergency cardiac management is as much a part of being an ICU nurse as having one-to-two patient assignment. Pretty cushy by most nurses’ standards.

As of tomorrow I am putting this on the job interview tool:

ICU is a physically demanding job. It involves lifting patients, pushing beds and carts, standing for long hours, moving quickly and interacting in a polite, respectful manner with patients and families. Do you have any restrictions that would prevent you from transferring a patient? How about pushing a bed or a crash cart? Getting equipment in a hurry or moving a patient who needs emergency surgery to the OR in a short period of time? How about maintaining an even, interested tone in your voice and not rolling your eyes and sighing in front of patients and families?



On a rant

The entire city is buried under a whirling blanket of snow and in order to put off, as long as possible the inevitable clearing of the walks, I will offer you my thoughts on this week’s health care news. I’ve already fed the cat, watched the snow blow, read my emails, checked facebook, fantasized about the latest real estate listings that have popped up in my inbox, checked out the upcoming conferences I won’t be able to attend and reviewed the amazon site for books I might like. What else can I do?

It’s been an interesting week in health care news. The Health Quality Council finally released their report into allegations made by the Raj about how the newly formed AHS (newly formed in 2008) was muzzling physicians and allowing politicians to jump the que in the supposed lines for health care. Oh yeah there was also the 200+ something Albertans who died while waiting for treatment for their cancer. So now they will have a judicial inquiry because if you can’t get people to voluntarily tell you about the patients they had who died waiting for surgery, compelling them by subpoena will work to get the information you want. If that doesn’t get results, well water boarding is always an option. Of course the whole thing – like so much in healthcare – is focusing on one aspect and missing the mark on the problems in health care. Doctors muzzled and unable to advocate for their patients? Consider that nurses, the ones who spend more hours per profession at your bedside and the ones who are uniquely positioned to know what the hell is going on with you on an intimate, personal level, have been muzzled for decades by physicians and administration. I dare say the same is true for all the health care professions since silence is the norm in health care.

A 2005 study conducted by the American Critical Care Nurses and Vitalsmarts found that most health care workers observed a co-worker taking a break from best practice and safety standards in delivering care to you and your loved ones but less that 10% of them spoke up and said anything. Why not? Well the culture in health care leads to a fear of speaking up. This is not new behaviour as a result of AHS domain, this is health care culture behaviour. And to be honest, it is in good part human culture. Speaking up violates the tribal rules of Stick-together. If we point out the mistakes of others, someone will point out our mistakes and no matter how much you insist you would want to know if you made a mistake, the gibbering monkey-brain lodged deep inside your skull does NOT like being singled out as doing something wrong. On top of that we have the human tendency to look for a scapegoat (see the above mentioned pointing of fingers at AHS). We determinedly look for someone to blame. Someone with a cookie in hand perhaps, or someone with a portfolio of health and a tile attached to him name. The reality is that this is no one individual’s fault and no judicial inquiry or investigation can fix it. A change in culture comes from generations of changing behaviours and attitudes. Another band-aid will not solve the problem.

In other news migraine suffering mothers have colicky babies. Or is it colicky babies have migraine suffering mothers? Could it be that colic, that dreaded syndrome of infancy, is in actuality childhood migraines? Of course the news report focuses on the headache aspect of the migraine syndrome – which is often not the best part. How about the abdominal pain, visual aberrations, somatic disturbances and my personal favourite, Alice-in-wonderland syndrome? As a colicky infant (according to mum, and who is going to dispute her?), grown into a child with constant stomach aches and trips down the rabbit-hole, gown into a dizzy, scintillation scotoma watching mum, I can verify the chain of events. Sure, I could blame my mother for continuing to feed me cow’s milk and wheat foods, but really, isn’t that just looking for the simple answer of Blame the Mother?

Oh and then there is the looming drug shortage. No, not the drugs from your UN-licensed pharmaceutical dispenser, the ones you get from your local shoppers. Sandoz Canada, the company that builds a large number of the drugs we use daily, has received a Stop It order from the FDA. Now, I can hear you asking, FDA? what the fuck do they get to say about a Canadian company manufacturing in Quebec (or if you didn’t ask, you should have). Simply, Sandoz makes drugs and ships to US and Canada and the FDA has some serious concerns about the plant’s inability to keep the microbiological contamination of the products down to a minimum. Now news reports says Sandoz won’t tell what drugs are effected, but insider information suggests that the list includes a good number of those medications we hold dear in health care. But don’t worry, we can always go back to what we did before – give you a bullet to bite on and bleed you. Perhaps you would be better served getting your medicinal products from the UN-licensed dispenser after all.

Oh and back to Alberta, the fearless opposition has again turned to pointing fingers about the ER wait time and demanded yet another inquiry. Seriously? How many of these do we need to have? We know the system is broken. We know people wait too long in the ER. we know EMS crews can’t off load fast enough and are held up in the ER when there is not a nurse, or a bed available for their patient. So until the public stops using the ER as their primary care facility this problem will exist. And as long as the public has no other option but to use the ER as their primary care, the problem will exist. And as long as there are not enough long term beds in the province, the problem will exist. The problem is not in the ER. The ER is simply the flashy front door of the madhouse. Sure, they can cure you in one hour at those efficient hospitals we all remember from days gone by – Chicago Hope, Mercy and what ever ER George Clooney worked in, but in real life it takes hours to get a radiologist in to blow open your carotid artery or review your brain scan. It can take a full day to get a neurologist down to see you about the dizziness you have had for 3 weeks but has suddenly become urgent, not because of any change but because there is nothing good on TV tonight. And don’t even think of dragging your 14 year old daughter into the ER and demanding we drug test her because she is acting unreasonable. She is 14, she is a raging hormone running on red bull and fried foods and we can’t legally do it.

And then there is the headline of shame that Canada doesn’t track the number of deaths nationally from percription drug overdose. Tsk, tsk. the news media in their fervor for something to whip people into a frenzy over have discovered that in BC there were, get ready for it – approximately 150 deaths from narcotic over dose per year between 2000-2009. Whew! In Ontario the number is higher. This is a health issue apparently because these predominately young and predominately men are offing themselves accidentally by snorting, shooting and otherwise intentionally abusing a medication they shouldn’t even have in their possession.

Well that’s it – there is so much more but I need to stop reading the news, it is altering my brain chemistry. Peace Out.

Bring out the scapegoat

It has been quite the week here in paradise. I really need to work on developing the aresolized ativan room spray – although what I would really like is some sort of spray that increases the self-awareness of the HUA syndrome.

Healthcare is always an interesting field to observe, for it is made up of people. People at their absolute best, people at their absolute worst and all shades in between. Tying those people together in a sticky web is the culture of the place, which can and often does mires us in immobility and a sense of victimhood.

I’ve thought quite a bit this week about Kimberly Hiatt, the nurse from Seattle who killed herself following the tragic medication error where she administered too much Calcium Chloride to her patient, an infant in the NICU. So many things are disturbing about this event and yes, it is awful and should not have happened that the child died, but the aftermath of that event provides us a very good window into seeing how it could have happened.

A google search of the news around these deaths will bring up headlines proclaiming that Kimberly ‘killed’ the patient, or made a ‘blunder’. Words are important and this type os sensationalized creates an impression she was intentional, even when the word accidental is inserted, or careless when she blundered. One report tells of the hospital being found blameless yet Kimberly was still under investigation when she took her own life. Yet, how can the hospital be found blameless while the nurse’s investigation was still underway. They are tied together unless the belief is that she intentionally overdosed the child. The hospital fired her following this event, which implies she was at fault, and fault implies that she could have done differently. She was then painted from that moment onwards as the nurse who made a careless blunder and killed a child, was fired from her career and under investigation. Since the hospital was blameless, it must have been her fault, and fault is what our society so dearly looks for.

This fault find, searching for a scapegoat culture in an industry that is so complex, creates a further layer of fear and mistrust where what is needed most is trust.

When I needed to arrange an interview this week between two nurses and the consultant from patient safety department who was doing a review of an event that occurred a week previously in our unit, the first thing the nurse who had been in charge ask was if she needed to bring in someone with her like her union representative. I carefully explained that the interview was not about finding out WHO was at fault, but rather about finding out HOW this happened and how could it be prevented from happening again. In a culture where you can be fired when an error happens you sense distrust that you can come forward and acknowledge and error made.

Another event shone a light on the complexity of the system when the discovery was made that using the Lifescan glucometer in an environment that had been cleaned with a hydrogen peroxide cleaner could result in false high readings. In the investigation into this it was discovered that someone somewhere in the organization had knowledge about this several months ago, but how did the information not get shared? Just exactly who do you talk to when you need to get such information out to such a wide group in a rapid time to prevent potential injury and error? No one seems to know and no one seems to be willing to take the step of making a wide sweeping recommendation about what to do. And so, another week will go by where the information remains held by a few. Communication is so very important but so very few of us do it well.

And deep inside this complex culture an experience nurse complains about trivial things – ‘Who is supposed to clean the mouse?’, ‘Why does the pyxis machine take so long to open?’, ‘the keyboard tray drops down too far!”, all indications of victimhood, deeply held belief that someone else is responsible and the completion of a workplace hazard identification rather than the self-awareness of individual responsibility.

In another place deep inside the complexity another nurse administers a potentially life altering medication. She was interrupted 5 times in the mixing and administering of that medication which was ordered by a physician and verified by the nurse as the correct drug because it was not legible, while the physician was accessing his iphone at the same time as talking to her, and obtained from the pyxis machine that dispensed the medication from the drawer which had been filled 2 hours earlier by a pharmacy technician who was new to the job, and decided upon by the care team based on information provided by the patient that he had only an allergy to some antibiotic, I think it was penicillin.

I wonder how many times I administered a medication that harmed a patient that I never even knew about.

Go safely about your business, there is nothing to see here. Move along.