Monday, June 22, 2009

Religious Views Dictating Referrals?

Once upon a time I was working in a very small town. An isolated, small town. In this town there were no doctors accepting new patients and no walk in clinics. This left the people with only one option for accessing health care without driving to another town--the emergency department.

So I had to temper my usual growls about people coming in for 'ankle pain x 3 weeks', 'sore throat', and 'prescription refill'. I got used to the fact that I was essentially working as a glorified clinic nurse and attempted to enjoy a stress-free existence.

Over the long weekend I triaged a young woman who came in requesting a referral to the gynecologists office. The doc who was working that day saw her and found out that she was wanting a therapeutic abortion (T.A). Because it was a long weekend and he wasn't sure how to set this up when the office was closed he advised her to come back during the week and the referral/appointment could be booked. She left.

A few days later she returned and I triaged her again, I recognized her and asked why she was back--I wasn't aware that she hadn't been given the referral. She explained and I looked at the large stack of charts ahead of her to come in. It was going to be a wait.

After being in the waiting room for a couple of hours I was able to bring her into the cast room (the only spot in the department that actually has walls). I figured she deserved the privacy as she had to explain her situation again and this was a small town where everyone knew everyone in the department and waiting room.

I while later I saw her walking out with a small scrap of paper in hand. The doc dropped her chart on the d/c pile and grabbed the next chart. A while later as I was processing all the d/c charts I noticed what was written, "Pt requesting referral to gyne for T.A. Explained that I am morally opposed to same and will not provide referral. Given information re: adoption options."

I'm sorry...what?

It was a zoo in the department at that time as it was shift change and people were coming and going. I was totally shocked by the d/c note but didn't really know what to say or so about it. The patient was long gone by the time I saw what had been done.

That night I was off for a run and found myself thinking about this girl and her situation. I was upset with myself for not doing anything to help her. It's not that I am hard lined about abortion and being pro-choice. My personal beliefs on the matter do not come into play when I am at work. I know that is an easy cop out for me as I am not being asked to perform them. What I do believe in VERY strongly however--is rural access to healthcare. If this patient was in the lower mainland she could walk down the street to the next ER or a clinic and get what she wanted.

In this town, she had no other option.

The ER was her entry point to the system and being stonewalled there by the ER physicians meant she was being denied access to a service which she has a legal right to seek in this country.

I got more and more angry with myself for not speaking up.

The next day at work I brought up the scenario with the charge nurse to see what her opinion on the matter was and how or if I should proceed. She became quite angry that the patient was refused the referral and while we were discussing it the doctor who originally saw the patient over the weekend overheard and interjected;

"I was the one that saw her initially...was she not given a referral?"

"No, the doc that saw her refused based on her religious beliefs".

At this point he talked about his own religious convictions and his pro-life beliefs. BUT he said it wasn't his place to determine if the patient received the referral or not, saying it was within his responsibility to provide the option if requested. He was quite angry and the patient was sent away and said that the doc should have "put down the bible and practiced medicine that day".

Pretty strong statement in my mind, especially since he's not exactly an abortion supporter. He asked we pull the chart, wrote the referral to the gyne, and I called the patient to tell her. I said if she wanted to go through with her plan it was up to her to call the office and make the appointment, but the paperwork had been done on her behalf.

It made me chew my fingernails for a few days as it stirred up many considerations around the issue and the problems faced by rural practitioners/patients.

Where do health providers draw the line at 'responsibility'? Is it in the referral? The procedure?

And what happens to those that don't receive the services they want...dangerous home remedies? Do they have the unwanted child? Does that child become one of our abused, neglected children or does he/she become a loved and adopted child? Or is the patient relieved the abortion never happened and happily become a parent?

As I said, I know it is easy for me to feel comfortable in my personal resolve on the matter this time but I am not the one being asked to perform the procedure. Would I? Could I? I don't plan on ever becoming a gyne so hopefully I never have to answer those questions.

But then I think...what if (once I am a doctor) someone wanted me to perform a procedure that I felt morally opposed to...would I be able to justify not committing the act but providing the referral?

Saturday, June 20, 2009

Tough As Nails

Today was a great day.

I grew up in the prairies, surrounded by farmers and ranchers. When older "Marlboro" men come in the department I get a twinge of familiarity that I get with no other population. It almost makes me a little nostalgic.

This older, eastern European farmer came in this morning after a tussle with a table saw. His right middle finger was lacerated in several places, including one long lac heading midline from the tip to the DIP joint. The nail was divided into one larger piece and several small flakes, the end of the finger was crushed to a pulp. His second finger had a 2 cm laceration to the lateral aspect, also from tip to DIP. I will admit that when I triaged him I looked at the finger wishing I'd get to be the one that got to repair it, but knew that it was way beyond my skill and experience in the land of sutures. Most of the docs I work with know of my expanded scope from working in the Arctic and thus let me do the straightforward sutures that come into the department.

Warning...if you are queasy about nails (Nature Nerd) you might want to stop reading now because I am going to go into the gory details on this one.

After he'd done the nerve block the middle finger the doc called me into the room and asked if I'd like to freeze the 2nd finger for suturing. I had never worked with this particular doc before but earlier had heard him asking one of the nurses why cardiac bloods had been ordered so I figured he was of the old school 'don't do it unless I order it first' mentality.

So I was pleasantly surprised when he asked me to inject the lido. He said he'd heard that I suture and asked if I'd also like to work through repairing the middle finger.


Outside voice: Yes, that would be great, if you don't mind walking me through it step by step.

The patient had already had his x-rays so we knew that the saw hadn't cut through the bone. He did the first adsorbable suture and then offered me the needle driver. Eeek! Hadn't done those before. I pieced together what I could inside the boggy tip.

After that we had to remove all of the bits of nail that were still attached. This meant essentially clamping the needle driver onto the end and pulling the nail off the bed. At first I couldn't get the technique but then saw how with rocking it back and forth eventually the nail just comes loose from the nail root and slips out. Feel free to shudder now.


Then the nasty part which was separating the nail from the nail bed which was still attached. If you want to see a video showing how this is done...voila. Yeah. He did a couple passes under the nail with the scissors...that is correct...scraping the nail from the nail bed, then offered me the scissors.


I was completely embarrassed but I was just concentrating on my breathing at that point.

I was getting that flushing feeling that comes over me just before I pass out...needed to breathe...did someone turn up the heat? Make the room smaller? Shine the light on my head?

I am blaming it on my low blood sugar but really it was just too much at that exact moment. I had just ripped off the other half of his nail for crying out loud! This was already a big day for me! I was starting to feel like a torturer in a Burmese prison.

Anyway, the sensation quickly passed (thank goodness--but not until after the patient joked that he hoped I wasn't planning on becoming a surgeon...har har). I was back at it to put in the sutures to close up the nail bed, the tip of the finger, and the rest of the laceration that went from the cuticle down to the first knuckle. Because the nail was so badly damaged and the patient didn't care if he ever regrew a nail, we did not reattach what remained.

So it was a nice close up to the nail bed, but it looked pretty hectic after that. To me, it was a thing of beauty! My first complicated laceration repair. I wanted to take a photo of it, but since I had no "before" to dazzle people with, I thought the "after" might leave some people wondering what I was so damn proud of.

I sutured the other finger, which was much more straight forward, though my first time ever going through the nail with a stitch. (Also super cool!) was so rewarding, and I learned so much during the procedure. Plus the doc was keen to teach and was very patient going through everything with me. The patient was really great about the procedure as well. He had actually apologised for coming into the department, telling us that it would have probably healed fine on it's own. He was sorry for bothering us.

We hastily reassured him that injuries like his are what ED are made for, and he could come in anytime without guilt with a chief complaint like that.

Sigh...salty old tough-as-nails farmers...gotta love 'em.

Thursday, June 11, 2009

Fly Like A Butterfly...

Last night a mother came in with her 9 year old who had just been stung by a bee.

He had had allergic reactions to stings 3 times in the past and was already showing some hives on his face, neck and arms. Very mild swelling to his eyelids was also starting to appear.

I was at triage and we were slammed but he was a priority so I whisked him into the department and poured some liquid diphenhydramine (benadryl) down his gullet before you could say "histamine response".

Mom was a nice, middle aged woman. We chatted about the risks of stings and the fact that she might want to look into an epi pen and liquid benadryl. Kid was sniffly and upset but not getting any worse. Mom told me last time he had a reaction it took 3 nurses to hold him down for the injection. I said he may not need one today depending on how the benadryl took effect (it seemed to be working).

Doc and med student saw him and he ordered an I.M injection of benadryl. I drew it up and went in the room to give it.

The child completely flipped out, running and hiding behind his mother, screaming, crying.

Mom just sits there with her hands folded in lap,

"oh Honey...the nurse is busy, let her give you the shot, remember we talked about where we will go eat after?"

Kid continues to freak out. I do not have time for this little episode...I walk away and tell mom to get him settled and I'll return with some more nurses. In the meantime I talk to the doc and see if we can give some oral ranitidine or maybe more oral benadryl...he is responding to the P.O meds so is an injection necessary? It is not going to be easy, I explain. But no, he says it will not absorb fast enough. Fine.

I come back with our male site leader and nursing student and ask them to hold with mom's help.

Mom continues to be useless at disciplining or calming child. The two other nurses are trying to hold him, I attempt to wrap him in a sheet which completely doesn't work.

Now kid is ballistic. Freaking out, screaming, kicking and punching as hard as he can. I am bent over trying to hold his hip still so I can give him the injection in the glute. In the process I get a kick to the abdomen (with shoes on, thanks) and punches/flailing arms to my upper body. My two colleagues are also getting kicked and punched by the child. Mom is the most impotent disciplinarian I have ever encountered. Her child is assaulting three health care professionals and all she's doing is saying, "oh, don't do that, stop it, come on....donnnn't...".

Finally I get the injection in after telling the kid to stop several times (and calling him a brat--I couldn't help myself). We walk out.

I was trying to mix some gentamycin up for a septecemia patient and my hands were shaking to the point I could hardly hold the vials. I have never been so furious at work in my life. Not only was I angry for being assaulted but I was also extremely upset that the mother didn't even apologise or discipline the child. Plus, the staff all just brushed the incident aside.

I was shocked at how upset I was actually. I was fighting tears over the whole thing and I couldn't figure out why I was so emotional after the event. When I had calmed down I returned to the room. Sat down and looked him in the eye. I apologised for calling him a brat. He evidently hadn't even heard me but accepted my apology anyway. He apologised for kicking and punching me. I offered, "friends?" and we shook on it.

I told him, sometimes at work people punch me, scratch me, kick me, even bite me.

"They BITE you???"


I went on to explain that we are nurses who are trying to do our jobs and it is very upsetting when the people we are trying to help are trying to hurt us. He said sorry again and said he wouldn't do it in the future. I walked out of the room, but have to admit, I couldn't bring myself to say what I wanted to the mother.

When I got home from my shift I took a long walk.

It was a beautiful night, just dark but still the warm air was hanging heavy. I was trying to unravel the nights events in my mind and look at my reaction to everything a little more objectively.

Why did only one co-worker ask me if I was alright?

Why did that mother not react to the way her child was acting?

Why is nursing the one job where being assaulted at work is an accepted job hazard?

I don't care that it was from a 9 year old. The whole event was unacceptable but I was unable to articulate it at the time. Or take the appropriate actions to deal with it. The "suck it up" mentality is very clear in nursing.

By the time I got home my lower back had completely seized up due to my poor body mechanics during the wrestling match avec needle. It's still very sore today despite my early morning hot yoga class in an attempt to work it out. I was in pain all day today at work but no, of course I didn't fill out any incident forms or make any complaints. Yeah, what am I going to say, "kicked and pulled by 9 year old, now suffering from lower back pain." Right.

To think about the monotonous regularity with which these events occur in the nursing profession makes me wince.

I just needed to vent a little.

Next time you see a nurse, give her hand a shake for all the sh*t we have to put up with. And then, when she sits down...give her a nice little shoulder rub (really get to those traps...).

Friday, June 5, 2009

Suddenly I feel Old

Why is the question, "how many years of school do you have to go back for?" always followed by "and how old are you?"