The Intensive Art

Dr. Wes: Once Again, the Airlines Have the Answer

I asked how many defibrillators (they) performed a year and asked who paid for them, and she said the government. “But we got authorization to do five more devices next year,” she said.

“Only five?” I asked in disbelief.

“Yep, and we were lucky. Other centers got fewer. They’re expensive, you know. We have to be very careful about who we select to get one of those. It’s not like America – people here are used to waiting.”

I live in Canada, and while I’m not an administrator who deals with budgets, supplies, and government bureaucracy, but I do have a healthy place within the chaos of reality. I feel that as an ICU nurse in one of the biggest and busiest ICUs in Canada, I at least have some perspective. 

Americans would love to have you believe that a Canadian ICU is merely a rickety shack with mud floors and a roof made out of twigs. They assume there’s no windows and the beds are made of straw. Our IV poles are made of cut down trees.

Americans would love to have you think that all our ICU patients (and surgical, cardiac, neuro patients etc.) are dying left and right because of our health care system. “Rationing” is the word used in Dr. Wes’s post. 

I have said it before, and I’ll said it again. In Canada, if you need surgery or any type of medical device, you get it. PERIOD. It is a decision between the doctor and the patient. The government doesn’t interfere in the decision making process. It has no say.

As for the defibrillators in the discussion, I have seen many patients sent for one. Usually it’s after some type of cardiac event that landed them in the ICU. A cardiology consult ensues and the decision is made to insert one. A date is selected.

Never once have they had to decide if a patient is “worthy.” Never have they had to choose if the patient should take up one of their precious rationed device. Never has the government called to say, “Sorry, we don’t want to pay for that.”  **

No! The patient needs it, the patient gets it.

And please, if my comments are wrong in any way, or if my beliefs about the Canadian healthcare system are inaccurate, please feel free to tell me, and I will gladly eat humble pie. I truly don’t consider myself an expert–simply a staunch defender.

However, please be someone who has experience working within the Canadian healthcare system, and NOT someone campaigning against universal healthcare in the US–because I have become well aware that these people will invent random inaccuracies about our system, simply to make us look bad.

And Dr. Wes, I adore you and your blog, and this has nothing to do with you–you are simply relaying a conversation that you had. I’m just trying to debunk a very common belief about our healthcare system.

**Although, I have heard of insurance companies pulling this in the US

Over the past couple years, I have received numerous questions from blog readers. Generally these questions go along the lines of, “Do you think I should be a nurse,” “Can you tell me more about what it’s like being a male nurse,” or “Do you know how I can get a nursing license in Canada?”

I receive as many as two or three questions per day. I’m not opposed to answering these questions per say, I simply don’t have the time. However, I DO absolutely appreciate anyone who has read my blog, and I am flattered that you feel I’m a worthy authority to answer your questions. 

Here’s my tip though, almost every question I have every been asked has been answered at length in different posts within my blog. Even more so, there are literally thousands of bloggers out there who have most likely answered your question in one form or another. So, I encourage you to explore other blogs as well–my links sidebar is a great start!

I love any comments or suggestions that you have, so please, don’t stop emailing and commenting! I just felt I needed to explain why I don’t always answer every email I get. 

That being said, I am going to make a new effort to answer emails occasionally, but in a blog post.

Thanks,

Sean

I was just over at emergiblog reading about the classes Kim is just finishing up. I too am struggling to finish the critical care course that I’m taking. My last test in my advanced physiology course is this afternoon and I’m working hard to cram my brain full of information.

This last unit is on the body’s defense systems, including: mediators, inflammation process, the immune response, and stress. Sure, it sounds simple enough, but as I quickly realized, this is by far the most intensely complex system in the body.

Everything has pathways and activators and mediators, and nothing has an easy name to remember. It’s things like C3a and IL-1. I’ve read the 150 page unit three times now and I feel as though I have learned nothing at all.

So, I sit here writing instead of studying. After all, would a fourth read really make a difference? It probably would. Actually, if I just slowed down and worked through the unit without rushing and skimming (this is the sixth unit, I’m getting a little restless) I’d probably easily figure everything out.

But it fascinates me that nurses are so inclined to continue their education. I think that nurses have an innate sense of wonder and curiosity that guides them through their lives. Like a two-year-old, they go through the day wondering “why?” over and over again.

Why is my patient’s urine output low? Why did the doctor order a c-reactive protein level in the blood-work? Why is my patient having shoulder pain after gallbladder surgery? Why has my patient all of a sudden started acting confused? Why do illnesses happen to some people and not others? Why is administration starting another committee to look at why we may need more committees?

Nurses are the type of people that run home and hit the books (or google) with that burning question that came up during the day. There’s that rush of happiness when you find the reason–and a bigger rush when you can explain the complicated answer the next day when someone else is equally puzzled.

I think I must declare: If you aren’t innately curious, dislike continually learning new things, hate to ask why, and simply just accept everything at face value, you may struggle as a nurse.

So, get out there, take a course, learn something new, and by all means, do it with pride and excitement!

Would someone please Please PLEASE come up for a cure for post-op delirium? It would put an end to crappy shifts like last night. There’s nothing like being told you’re an alien that has kidnapped all the patients from the hospital…and you must be killed at all cost! This while desperately trying to keep a foley and central line from being pulled out. Oh, the blood splatters that would have caused! Then came the swinging fists. Ugh!

It’s 00:43 and I’m between night shifts, and I’m having a happy dreamy night. It’s been a great weekend, and today was particularly great! It included: taking my dog to get his picture taken with Santa, drinking some of the world’s best coffee, and putting up our Christmas tree.

So, right now I’m continuing with the dreamy times (Grey’s Anatomy would be proud of all this dreaminess). I’m sitting in front of my dreamy tree:

And drinking some dreamy coffee that was ground in my new grinder and made in a press:

From one of the bestest dreamiest coffee roasters in the world!

I really can’t wax poetic enough about 49th Parallel coffee. While the Ethiopian Yergacheffe shown above is amazing, their “sleeping woman” is quite honestly the greatest cup of coffee I have ever had in my life. And on order are two more coffees from them that are considered even MORE incredible. I feel like I’ve truly discovered a treasure…and I’m trying to decided whether I should share it or keep it all to myself!

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So, I wanted to catch up on a few things that I’ve been meaning to post about! First of all, I was tagged by Peter over at St. Vincent’s Hospital Darlinghurst. He asked about my proudest moment.

It won’t be a long answer because it is short and simple. My proudest moment was when I received the letter in the mail telling me I passed the RN exam. The size of the accomplishment crashed down on me at that very moment and I bawled. My last day of school, my professor saying she’d recommend me for grad school, and even receiving my diploma didn’t feel as good as that simple scrap of paper stamped “pass.”

And I’m not just saying that because it’s a nursing blog. It was a culmination of so many struggles. I’m still proud of me. Yay!

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Kim over at Emergiblog has been talking about clinical vs. theoretical experience. She put out a call for opinions on the subject. Disappearing John RN has already put in his opinion on the subject.

As for my education, I feel that there was a strong balance between clinical and theoretical nursing. We spent hundreds of hours in the clinical setting putting our lab skills to practice. In fact, I think the only way they could improve our clinical experience would be to go back to hospital training programs.

The issue I had with my education and clinical training is that it offered a Pollyannic and unrealistic. They taught us how to holistically care for patients physically, spiritually, and emotionally. The reality is that the hospital system only supports caring for the physical. If you have time to sit down and talk emotions with your patient, then you have time for more patients!

We work in a system that rewards technical skill over holistic care.

The other issue with the education we received is that they preach a style of nursing that doesn’t exist, and to be honest may never exist. That is, they teach us to be leaders of a team of people. They teach us to delegate tasks to those around us so that we may orchestrate a complete and effective care that (sorry, I’m sounding like a broken record here) cares for the patient holistically.

I think that nursing NEEDS to go to this style of care because as the numbers of RNs wane, we will be replaced with technicians that require strong leadership and supervision. However, I believe that this will take decades to occur because nurses push away the idea more strongly than they fight for nurse/patient ratios.

I, personally, went into nursing thinking I would be exactly what I described: a leader of a team of folks working to care for patients. I truly didn’t know nursing would be as it is–oops! So, for me, the idea of transforming what nursing looks like is an exciting prospect. However, many nurses went into nursing because they loved the idea of caring for patients: washing them, changing them, walking them (I often think we describe caring for patients as we would caring for a dog). To them, the idea of stepping up our focus and moving slightly away from the bedside is a slap in the face to the profession of nursing.

I think nursing will transform, but we won’t allow it to, so it will have to happen out of necessity rather than will.

So, to answer Kim’s question point-blank: I feel that my nursing degree prepared me very well, but it prepared me for the wrong thing!

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Beth over at PixelRN posted some ideas for blogging topics. This one stood out for me:

3. Advice for fellow nurses. Everyone loves to give advice, lets face it. As a nurse blogger, you have the ultimate soapbox!

OK, I don’t have an entire post devoted to the topic, but I did want to answer with my advice. And it’s simple! My advice is to RELAX sometimes. Yes, it’s a stressful, busy, scary, sometimes hopeless job. But please, don’t forget, it’s OK to be yourself, have some fun, laugh occasionally, look for the positive, and as I said:

RELAX!

It’s cold here! Last time I checked it was -18C (I’m not good at fahrenheit conversions for ll the American folks out there), which is even cold for a person like me who hates heat. However, it gives me a chance to bundle up in my 2006 Canadian Winter Olympics gear which I adore.

I have a couple days off before switching back to nights. I have been working 12 hour days for a months now, and I’m ready to be a night person again! I am tired of hearing that alarm go off at 05:00am. It will be nice to be back to where I feel more comfortable.

I was working in our unit’s high observation room for the last few days. I adore working in there! For starters, we have a 2:1 nurse/patient ratio (the room fits four patients). This means that while working together, we get an incredibly good amount of stuff done for our patients. I wish it was always so good.

The other thing I like about the high obs room is the high acuity of the patients. Some nurses can’t stand unstable patients, but I’ll be honest: the more unstable the patient, the more interesting they are to me! This is the reason I fully plan on moving to the ICU and working toward being on the hospital’s code team.

Speaking of the ICU, I wrote another of my critical care nursing course tests yesterday. This one was brutal. It was renal physiology, which I generally find fairly straight forward, logical, and easy to learn. However, I just didn’t have a lot of time I could devote to studying for the test. I don’t have my results back, but I don’t think I will see a mark above 90% like the other tests; and frankly, I don’t deserve a high mark.

Yesterday, we had a large staff meeting. We’re tired of being chronically understaffed; we’re tired of having patients lining the hallways because administration forces us to take many patients over our unit’s capacity; we’re tired of our incompetent manager; we’re tired of so many things.

We compiled a list of our complaints about our manager and the hospital. Then, we backed up all our complaints with research and numerous personal experiences. We also cited our nursing association’s practice standards. Then, one of us (thank God for her!) stood up in front of about thirty unit staff, our manager, and two of her managers, and listed our complaints and demands.

We called for serious action!

We really didn’t get any. The answer we received was basically, “We here what you say, we believe what you say, we understand what you say, but we have no solution…so sorry. You still need to work understaffed and over capacity.”

The only step forward was the creation of a “unit council” that will meet with the goal of coming up with solutions to our problem. The administrators are pushing us to reform our nursing model. They want to use a much more multidisciplinary approach to nursing.

In this model, nurses would be “case managers” as they described it, and would manage a team of multidisciplinary individuals. Instead of providing direct nursing care, the RN would direct a team of individuals to provide care of patients.

They even suggested adding extra staff to the unit, such as: pharm techs, physio techs, Recreation therapists, and whatever else we could imagine. Their thinking is that we could utilize the appropriate resources to provide well-rounded care to our patients.

I personally a very strong advocate of this style of nursing. When I went into nursing, this is actually what I thought being an RN. That is, I thought RNs were the supervisors on the unit that gave orders to LPN’s and NA’s to provide care to patients. I thought they were the case managers that I just described.

I am always embarrassed to admit that when I started nursing school, I didn’t think RN’s did bed baths, or changed diapers, or toileted patients. Even after the first year of nursing school I was under the impression that we were just learning those skills because we would have to supervise others while they performed them. So, it was a bit of a shock in the second year of nursing school when I came to the realization that these tasks WERE a part of my job.

The major opposition to this approach is nurses who went into this profession because they wanted to do the bed baths, toileting, attends changes. They refuse to let go of these items simply because it’s the part of the job they think IS nursing.

As I’m a recently trained nurse, I was taught that being a RN means working at a much higher level. Nursing, the way I was trained, is about being a leader of a multidisciplinary team focused on implementing a holistic plan of care that cares for the patient both physically, spiritually, and mentally.

I truly believe that a lot of nurse’s skills are wasted! We only use a small fraction of our scope of practice. And the fraction we use is stuff that other professionals can perform. It’s stuff that, were it to be let go of, would allow us to work at a higher, more intellectual level, and (God forbed!) be seen as professionals, rather than blue collar workers.

We deserve a step forward in our profession!

Sorry, that was longer than I intended….

After our meeting, we went out to dinner. It was so much fun hanging out with the folks from work and gossiping. I don’t get invited to a lot of events (every event seems to be a bridal shower or baby shower…no men allowed!), so it felt good to be chummy with my friends from work.

Today, I’m looking forward to getting a small amount of Christmas shopping done. But, I’m not too stressed out about it. I typically enjoy doing my shopping closer to Christmas day. Seriously, it just FEELS more like Christmas when you actually buy your presents around Christmas. Buying everything in August just isn’t the same.

Well, as expected, my first shift back after being off for a week (most of it sick) was absolutely horrible. Isn’t that always the way? You feel rested, relaxed, recharged, energized and newly excited about your profession. Then you walk in and within ten minutes you are reminded of exactly why you keep getting burnt out. 

Some of you are thinking, “what? You haven’t even been out of school a year and you’re using the ‘B’ word?” However, for me, burnout isn’t an end of the road situation for me. Instead, I find that it is a cycle that ebbs and flows over time. 

Last night I had fresh post-op patients, new ICU admits, a psychotic patient, a total care patient, a patient that needed excessive toileting (ARG! I hate walking little old ladies/men to the bathroom several times a night when they are sloooooow!), two others that kept me busy by frequently asking for menial tasks. Yes, there’s nothing like that desperate call from a patient because they need their perfectly fine leg moved two inches to the left! We had one of these conversations:

“Nurse Sean, can you move my leg two inches to the left?”

“Why don’t you try adjusting it yourself?”

“Oh! OK, is that allowed?”

I had two patients on tubefeeds, almost all the patients were on q6h sliding scale insulin, one had a heparin drip that needed to be titrated, three were having low blood pressure issues, two others had low urine outputs, one needed discharge paperwork started, another needed to be prepped for a CT scan. On top of all this, administration insisted that we start lining our halls with new patients even though we were short staffed.

I think if I could choose one factor that contributes most to my burnout, it would be a complete lack of control over my environment at work. I have no say in my patient assignment (I can request a change, but it isn’t likely), so if I feel I have too many patients and feel unsafe I have no recourse. If five nurses call in sick but they still insist on filling up our unit far past capacity, we don’t have the ability to stop admissions because we just can’t handle more. I can’t tell doctors that certain procedures will have to wait until morning because I have too much on my plate. In situations like these, I am simply told, “too bad, deal with it.” And usually very rudely.

So, last night my mind was filled with the question of how can nurses  regain control of their own work environment. The only resolution I could come up with was regarding our union contract. I firmly made the decision that I will never say yes to a contract unless it includes some way for nurses to refuse dangerous workloads. Until nurses have the ability to say “no,” I will not be agreeing to anything.

Sure, this may mean that I never vote yes on a contract again, but I believe nurses have massive pools of power that they never use! Instead, they sit around the break room and complain about their jobs without taking action. Imagine if every nurse decided they would never sign a contract or work in a job unless it gave the nurse more power over the safety of their environment! 

Come on nurses, use your power! If you don’t like something, find a way to fight it! Even if the only recourse is to withdraw your yes vote. 

I need to get this off my chest. I am very interested in the debate in the US between private health care and public health care. I am a Canadian and have lived under a socialized system for my entire life. I am tired of reading blogs and forum posts that continue to perpetuate complete myths about socialized health care. These are the main ones I hear that I would like to dispel: 

1. You will no longer have any choice over your doctor or what hospital you can go to. The government assigns doctors to you! 

Ok, I honestly don’t know where this comes from! Doctors are never assigned to people in this country!

Here’s how you get a doctor in my city: first, you go onto the website for my city and click on the link entitled, “Doctors that are accepting patients,” secondly, you choose the area of the city you live or work in…or whatever part of the city you want to travel to to see a doctor. Thirdly, you look at the list of doctors and choose one. In order to help you choose the doctor you can look at comments provided by patients of these doctors on how they rate their services. This process of choice is the same whether you are homeless or a millionaire.

As for choosing a hospital, well, they are all run by the same executives and follow the same policies. Choosing different hospitals won’t get you better care. In fact, each hospital strives to give equally great care. Choice is based on location and availability of beds. 

2. The government controls what the doctor can and cannot do!

Please! The government wishes they were this powerful!

Plain and simply, doctors do not work for the government. They are self employed. The only difference is that they send the bill for their services (as do the hospitals) to the government as opposed to the patient or their insurance company.

Doctors answer only to their licensing body, as do nurses and all health care professionals.

In fact, I think there’s much more freedom for doctors. They don’t need approval from insurance companies for procedures. The doctor is in control of what is necessary and it is more likely to be based on the patient’s needs than profit margins. 

3. You have to wait months to get into the hospital or go for procedures!  

Sometimes this is true! But only for minor surgeries that are being done for comfort reasons. For example, if someone needs a knee or hip replacement because it’s painful to walk they may have to wait a little while (but not the exaggerated amounts of time that you hear).

And no, patients don’t walk around with broken hips. If you are in trouble and you need help right away, you get it right away! I’m tired of hearing ridiculous stories of patients who have to wait months for emergency bypass surgery, or years to get their ruptured appendix dealt with. 

Sure, you hear about people going to the states for procedures. However, this is for the extremely wealthy. If someone said to me, “you can pay $20,000 and have your knee replaced tomorrow, or wait a couple months and have it done for free,” well, I’ll wait! Going to the US for procedures is absolutely NOT as common as people think

4. The US has the absolute best health care in the world! People flock from all over the world to have procedures done here.

I hate to break it to everyone, but (brace yourself) all that technology that you have is miraculously available in the rest of the world as well!!!   

*gasp!*

Don’t flatter yourself. All the things you can do in the US can be done everywhere else. In fact, on my particular unit, the doctors specialize in a particular cutting edge procedure. Patients flock here from the US and all over the world to have it done. 

5. If the government runs the health care system, the bureaucracy will run the hospitals into the ground!

Are you kidding? The government is the only place billed. There’s no paperwork to fill out, just a healthcare number to keep on the chart. There’s no billing department to send out itemized bills to patients, insurance companies, etc. The administrative side of public healthcare is incredibly streamlined.

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OK, that’s all I can think of for now. I’m sorry if I offend. I simply am tired of people telling me all about this crappy system I work in when really they are completely misinformed about how this system works. 

How could I not love the fact that I showed up for work, sniffling, coughing, dripping from my cold, only to discover I made a mistake and didn’t have to work. And by some miracle, we weren’t short-staffed. So, here I am, back at home to enjoy another night watching movies and reading blogs! Sweet!