Let's Just Think...

Alcohol

When I started college, I entered as an English major with a passion for Emerson and Thoreau as well as poetry and Russian literature (an interest that started in high school). I had "a thing" for Anton Chekhov and his short stories, several of which hovered on the topic of drinking and alcoholism and all of the turbulance that accompanies it. 

As my freshman year transcended to my sophomore year, I changed majors again and again and again. It got to the point where I would call my parents and my mother would ask "So, what are we majoring in today?"  - As Jimmy Buffett once said "I may or may not be indecisive".

Having finally ended up majoring in Psychology, I never really gave up my passion for literature and poetry because of the way the novels and stories that I read accentuted the lessons I learned in my Psychology courses: Abnormal Psychology, Developmental Theory and one of my favorite courses of all time - Perception and Psychophysics.

When the topics of addiction and alcoholism came up in our senior Psychology seminar, Anton Chekhov returned to my life.  It was never just "psych" it was the lessons of Erickson, Skinner and James along with those who wrote about relationships, history and  the consequences that came "with a dream deferred".

Over the weekend,  a masterful lesson in Alcoholism extended throughout our hospital in a way that was like a fishing net cast over a wide ocean. In one part of the hospital, a patient was detoxing and trying to communicate her needs through shaking and the slurred speech. She referred to my colleague as her sister and asked her family (none of whom were present in the room), to "push in the chair!!".

Our discussion flowed into a collaborative fusion of our knowledge via lessons learned from our own insightful experiences and lessons learned from alcohol: previous use, abuse, relationship struggles with our families, our children and our own upbringing. Everyone from the physicians to the nurses and techs had both similar and different perspectives of alcoholism and addiction. It was fascinating to watch as the topic seemed to hover like a stormy cloud on the second floor until it got on the elevator and headed downstairs to our Emergency Department. 

The two traumas were called right around shift change. A car accident with two people needing to be "extracted" from their vehicles. 

Like the progression of addiction, the rest of the night became worse as each moment went from one discussion to the next. I looked at my colleagues working feverishly to save each life in the two trauma rooms in our department. Then looked into the faces of the families as we told them the news of their critical loved ones. 

Nothing good comes of alcohol use. 

I walked into the chapel, our Chaplin who had been called in met with one family while the other family still sat quietly in our consult room - waiting for more news. It seemed like everyone was crying.

Our clinical team was steadfast in the way they navigated through hours of care for our patients and their families. In the end, one patient had died while the other remained in critical condition, stable enough to be transferred to receive the continued care he needed. His wife sat stoically in the passenger side of the ambulance. I waved as I walked by her hoping she had the inner strength to get through the next several hours. 

Nothing good comes of alcohol use.

A life once filled with an immense amount of talent and potential was gone. Two families will never be the same. 

Anton Chekhov once said: " We shall find peace. We shall hear angels, we shall see the sky sparkling with diamonds."

Are We Providing Good Care or Fostering the "F"?

If you look at the map, our hospital in WV is about 2300 miles from Tucson Arizona where 1 year ago today we shared our prayers along with feelings of sadness and loss with six families who lost a loved one as a result of the actions of a young man with mental illness. With 13 other individuals wounded in the same event, it is difficult to avoid taking a long hard stare at the way mental illnesses have affected our lives, our state and our nation.

At our hospital, we see patients with mental illnesses frequently. Is this surprising? – No. The National Alliance on Mental Illness (NAMI) website reports that “we’ve all been hit by the worst economic times and highest unemployment in more than 25 years. Those unemployed workers are reporting symptoms of severe mental illness four times more than people who still have jobs. Four times as many report thoughts of suicide.” Additionally, NAMI reports, “returning combat veterans are experiencing very high rates of serious mental illness, suicide, addiction, homelessness, and incarceration related to posttraumatic stress disorder.”

“How are you?” I frequently ask the patients and families in our Emergency Department who have presented with symptoms of mental illnesses. The responses usually consist of a wide range of issues and situations that are not easily solved within the few hours they are with us: “I’m about to lose my house”, I’ve been out of work for the last year and a half and can’t find anything”, “ I just found out I had cancer”, - or – what I think of as the ‘perfect storm’ of emotions and stress:  “my wife and I aren’t getting along – ever since I lost my job, we’ve had financial arguments which are affecting our relationship and the children, the house is about to get foreclosed...we have no where to go”.

Each story seems more heart wrenching then the one that came before it. But what is even more difficult is looking into the eyes of the patients across from me and seeing their ‘heart’; their emotional pain, vulnerability, frustration, fear, anger, hurt, abandonment, disappointment - you name it, the emotions are there. Emotions that sometimes lie buried under situations or dynamics of fighting to keep your family together or pounding the pavement looking for a job only to face rejection over and over and over again.

And yet, as heart-wrenching as these stories are, I’m glad to be having a conversation with each patient as opposed to helping families with locating a funeral home and additional support after the successful suicide of a loved one.

In 2009, the National Alliance on Mental Illness published their report “Grading the States” which listed West Virginia having a grade of “F” (the national average was a “D” – which was the grade given to West Virginia in NAMI’s 2006 report). Arizona – where the shootings in Tucson took place, received a grade of a “C” in 2009. Just under ten miles from the east of us, Maryland received a “B” – one of the highest grades in the country as there were no states that were worthy of an “A”.

But what do these grades mean?

In short, they mean that we (those of us providing care for our patients and families) need to be better then we are. We need to have the open discussions about the provision of care for patients and families who present to Emergency Departments with suicidal ideation, depression, anxiety, bipolar, schizophrenia and addictions and understand that all of these are real, treatable illnesses and not major character flaws. We need to understand that the face of mental illness is not some stranger off the street – it’s the patients and families in our care, our co-workers, our neighbors, our friends, our families and sometimes ourselves.

We need to protect and strengthen out state’s mental health care system and understand that doing so is an investment that will provide real benefits for patients and families in providing them with the care, support and resources necessary to address the illnesses they have.

As providers and as a community, we should also ask ourselves how we can apply the lessons learned from the events in Tucson to our own communities. In his Statement on The Arizona Tragedy and Mental Health Care, Michael Fitzpatrick, the Executive Director of the National Alliance on Mental Illness stressed the importance to “objectively determine every factor that may have contributed to this tragedy so we can act on lessons learned”.

He specifically listed ten questions to begin this process which included asking:
1.      Was there a diagnosis?
2.      What is the full medical history?
3.      When were the symptoms first noticed?
4.      Did family members receive education about mental illness and support?
5.      Did the person or family ever seek treatment only to have it delayed or denied?
6.      Was the person seen by mental health professionals? By whom? How often?
7.      Was treatment coordinated among different professionals?
8.      Was the person prescribed medication? Was it being taken? If not, why not?
9.      Was substance abuse involved?
10.     What may have triggered this psychiatric crisis?

Here are my questions:

What would the care provided for patients and families in West Virginia look like if we asked these 10 questions on every patient in our care? Would West Virginia still have an “F”? What if we implemented similar processes to those of our “B” grade Maryland colleagues. What if we looked at the vast difference in the commitment process for patients in Maryland vs those in West Virginia and made adjustments as needed to insure safe and expeditious access to care? 

I wonder if it is a coincidence that two of the states with the highest grades: New York and Maryland are also referred to as “2PC” states; states which require two physicians to commit a patient where as states with lower grades (including West Virginia) do not have that process in place? I wonder if implementing the 2PC process in West Virginia would be more cost effective then the presently established treatment process?

While I like to think this is an easily attainable goal, sometimes the more important task is just to provide good care for the patients we see instead of letting them (and their families) "slip through the cracks" again and again by not acknowledging the presence of their symptoms or their need for care.

We have to look back at the intricate needs of each state's NAMI report card and the symptoms and goals of the patients and families in our care and ask ourselves:
Are we providing good care or fostering the "F"? 

"Hold Her Until You Fall"

Our patient had overdosed on a substantial amount of over-the-counter medication. He was admitted to our hospital and the next day, the Resident caring for the patient informed me that he wouldn’t be able to leave our hospital until he spoke with me. 

When I arrived to his room, our patient (surrounded by an extremely supportive family) informed me that his overdose was impulsive and precipitated by an argument with his grandfather. While he informed me that he didn’t intend to take the pills, he expressed his frustration with his relationship with his grandfather and the shame involved with having to move back home as a result of the break-up of his relationship and the loss of his job.  He had also recently gained custody of his daughter (an infant).

He informed me that, after the argument, he took the pills, realized what he had done and came to our hospital. 

His grandfather had a slightly different story of the events that took place that day.

He informed me that there had been an argument about an extremely inconsequential topic. That his son became angry and left the room. His wife, upon seeing her grandson lift his cupped hand to his mouth, asked him “did you take those pills?”. 

“No” said our patient. 

When asked again by his grandfather if he had taken the pills, he admitted that he had. He informed his family that he didn’t feel his life had meaning, that it wasn’t worth living. He said he didn’t want to go to the hospital and didn’t want to receive help. As his grandfather recounted the story, the patient looked down at the floor, not wanting to make eye contact with any of the members of his family present in the room at the time. 

The patient’s grandfather had a look in his eyes I will not forget. He looked right at me with fierce determination and said: “I picked up his daughter and put her in his arms and I said to him ‘If this is the last time she’s going to see you, I want you to hold her and look into her eyes until you fall’.”

We all stood together silently in the room; it was almost like a prayer - the legacy and loving support of an entire family surrounding a son - adrift. 

“Then what happened?” I asked

Lifting his gaze from the floor, the patient looked at me and said “I told them to get me to the hospital.”

First We Kidnap All The Walmart Greeters....

"What do you do?" Asks the woman sitting next to me on the flight home from Sarasota FL.

"I'm a Clinical Navigator at a hospital" I tell her.

Silence. (I can feel the processing going on. Wait for it......)

"Now tell me just what that involves" she says.

I explain to her some of the different events of my day and how it relates to patient care, service excellence and conflict resolution and loss and grief. I'm thinking that I also want to tell her about my intense love of pizza and where the best coffee is in the hospital but I decide to hold off. 

She tells me about her previous healthcare experiences at her local hospital in Pennsylvania. About sitting in the ER hearing a patient nearby explain to her physician that she is supposed to be admitted to the medical floor having been referred to the hospital by her primary physician to be admitted. "I heard her ask - several times - 'why is this taking so long? I'm supposed to be here'. It seems like there were problems with communication".

"The Emergency Room in our hospital is owned by a separate company; they don't work for the hospital. We even have a sign that tells you how many minutes you have to wait to be seen in the ER" she tells me, "but it always seems like you have to wait a long time". "I always wonder about that" I tell her, never being sure if the sign refers to the time to be seen by the triage nurse, the physician or just having someone say 'hello' to you when you walk in the door. (My brother and I had passed the sign to Doctors Hospital in Sarasota less then an hour earlier, on the way to the airport, that read "Wait time: 22 Minutes").

I thought about how cool it would be if we could steal all the "Greeters" from Walmart and have them stand just inside the door of the ER and say 'hello' as soon as patients and their families walked through the door. Maybe they would change all the signs: "Wait Time: 4 Seconds".

Not only that but we could also eliminate those fashionable blue vests...

But I digest...

On the plane I heard at least three different stories of healthcare experiences from my friend - all interesting, somewhat negative, and relevant to the same challenges faced by many hospitals. As I glanced at the other passengers sitting near us, it occurred to me that probably every person on the plane (a very full Boeing 717 that held about 115 passengers) probably has at least one story about a healthcare experience they (or someone in their family) has had.

I always wonder about the stories behind the numbers. 

 

Healthcare Fault Lines: Mental Illness

One of the most difficult to navigate "fault lines" in any emergency department or hospital is access to care for patients with mental illnesses. Even with hospitals that have inpatient behavioral health units in their hospitals, getting patients "upstairs" to the care and the treatment they need can be extremely challenging. 

For patients and families enduring the challenges of mental illness on a daily basis, this fault line can be extremely frustrating as well. - Personally and professionally, there is nothing more exasperating then having to endure the stigma of mental illness (as described in the video above) and have the necessary discussions to be able to access the care you need. In an ER, this is also challenging because of the nature of the disclosures you need to make to get the help you need to providers who who use strong defenses to endure the emotional challenges of their day and the needs of all of the patients in their care.

It's not easy, but it is necessary.

The National Alliance for Mental Illness reports:

"One in 17 people in America lives with a serious mental illnesses such as schizophrenia, major depression, or bipolar disorder. About one in 10 children live with a serious mental disorder. In recent years, the worst recession in the U.S. since the Great Depression has dramatically impacted an already inadequate public mental health system. From 2009 to 2011, massive cuts to non-Medicaid state mental health spending totaled nearly $1.6 billion dollars. And, deeper cuts are projected in 2011 and 2012. States have cuts vital services for tens of thousands of youth and adults living with the most serious mental illness. These services include community and hospital based psychiatric care, housing and access to medications."

Additional information provided by the National Alliance for Mental Illness includes the following:

• Mental illnesses are serious medical illnesses. They cannot be overcome through "will power" and are not related to a person's "character" or intelligence. Mental illness falls along a continuum of severity. Even though mental illness is widespread in the population, the main burden of illness is concentrated in a much smaller proportion-about 6 percent, or 1 in 17 Americans-who live with a serious mental illness. The National Institute of Mental Health reports that One in four adults-approximately 57.7 million Americans-experience a mental health disorder in a given year.
• The U.S. Surgeon General reports that 10 percent of children and adolescents in the United States suffer from serious emotional and mental disorders that cause significant functional impairment in their day-to-day lives at home, in school and with peers.
• The World Health Organization has reported that four of the 10 leading causes of disability in the US and other developed countries are mental disorders. By 2020, Major Depressive illness will be the leading cause of disability in the world for women and children.
• Mental illness usually strike individuals in the prime of their lives, often during adolescence and young adulthood. All ages are susceptible, but the young and the old are especially vulnerable.
• Without treatment the consequences of mental illness for the individual and society are staggering: unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, suicide and wasted lives; The economic cost of untreated mental illness is more than 100 billion dollars each year in the United States.
• The best treatments for serious mental illnesses today are highly effective; between 70 and 90 percent of individuals have significant reduction of symptoms and improved quality of life with a combination of pharmacological and psychosocial treatments and supports.
• With appropriate effective medication and a wide range of services tailored to their needs, most people who live with serious mental illnesses can significantly reduce the impact of their illness and find a satisfying measure of achievement and independence. A key concept is to develop expertise in developing strategies to manage the illness process.
• Early identification and treatment is of vital importance; By ensuring access to the treatment and recovery supports that are proven effective, recovery is accelerated and the further harm related to the course of illness is minimized.
• Stigma erodes confidence that mental disorders are real, treatable health conditions. We have allowed stigma and a now unwarranted sense of hopelessness to erect attitudinal, structural and financial barriers to effective treatment and recovery. It is time to take these barriers down.

We, as providers and individuals have miles to go to access the levels of care  that our patients and families deserve; but as the Chinese philosopher Lao-tzu said: "A journey of a thousand miles begins with a single step."

If you or a loved one needs help and is in crisis and seeks help in an Emergency Department, here are 5 things that can help:

1. Bring any medications and dosages that the patient is presently prescribed with you and provide to the healthcare team.

2. Bring the names and contact information of the patient's providers and, if you can, contact them to let them know you (or your family member) are in crisis.

3. Be prepared to wait: accessing care for patients can sometimes take hours depending on bed availability and transportation.

4. If the patient is not willing to seek help on a voluntary basis, let the providers know of your concerns and why you feel inpatient involuntary treatment is needed. Let them know the symptoms you have seen starting with the most acute symptoms first. If you are concerned about your (and your family member's) safety - let people know.

5. If you are in immediate crisis, don't hesitate to contact the National Suicide Prevention lifeline at 1.800.273.8255

Need Additional Information? If so, contact the following:

• National Institute of Mental Health
• National Alliance for Mental Illness
• National Institute for Alcoholism and Alcohol Abuse
• National Institute on Drug Abuse
• Treatment Advocacy Center
• Article: A Mental Health Crisis In Emergency Care
• American Foundation for Suicide Prevention: Risk Factors
• Sidran Institute
• Suicide Prevention Lifeline
• Bring Change 2 Mind

Thanks for your help and support!

Of Death, Angels & Dinosaurs

 

Our 6 y/o little guy and his younger sister were standing alongside the stretcher holding his mom’s hand while his father encompassed both of them in his outstretched arms. All of them were crying.

“I’m going to miss mommy.” he said. 

“She’s going to be with the angels - watching over you wherever you are. When you have sad days, she’ll be there with you and when you have good days when you’re doing something you love like playing soccer, she’ll be there with you too”, I told him. His little sister watched quietly - her eyes following her brother’s movements.

Then, far from left field and presented in a manner that only 6 year olds can, he announced “I like dinosaurs!”.

“I do too” I told him, trying to think of the scary one from Jurassic Park but not able to remember as a result of where we were and what had just happened.  It didn’t matter; he continued to tell me about how many dinosaurs he had and that he had received one for Christmas. Remembering this gift also brought him back to the present and the sadness that he felt - I could see it in his beautiful dark eyes as they transcended from happy thoughts of dinosaurs to looking back at his sister, his father and then down towards the floor.

There is a long journey ahead for this family.

At the end of the day - as we sat quietly in the chapel, the lessons for me came back to the two that I have come to know best that are most familiar to me now:

1. That sometimes it is more important to just be with someone then it is to try to fix what has happened.
2. That when those closest to us die, we remember how we loved them and, more importantly, that they were loved. 

Mission Congruence

Several years ago while driving on route 95 to New Haven, I looked up and saw a sign that said "Yale New Haven Medical Center: Advancing Medicine Since 1839."

1839: Since before the civil war; Martin Van Buren was President.

Now there's a legacy.

We (as a nation) have a come a long way since then. So has Yale New Haven Hospital as their mission is: "..to provide sensitive, high-quality, cost-effective health care services to all patients, regardless of ability to pay; to be the primary teaching hospital for Yale School of Medicine and offer training opportunities for nurses and allied health care professionals; to provide the setting for ongoing clinical research that helps bring medical advances from the laboratory to the patient's bedside; and to serve the community as a public health advocate and provide support and services which respond to the area's health care needs through health education, health promotion and access to care."

Sometimes when I'm bored - I look up the missions of the hospitals where I've worked (or been a patient myself) - just to see what drives (philosophically) the teams who are caring for me.

Here's what I've found so far (and yes, for the record, a member of my family was at Yale):

Holyoke Medical Center (MA): "Our aim is to ensure that when you turn to us for help, your experience will be as comfortable and convenient as possible. At Holyoke Medical Center, we’ll treat you right."

Rutland Regional Medical Center (VT) - Vision: "To be the Best Community Hospital and Health System in New England" 

Dartmouth Hitchcock Medical Center (NH): We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.

The Stonington Institute (CT): To provide superior behavioral healthcare services that: clients recommend to families and friends, physicians prefer for their clients, purchasers select for their clients, and employees are proud of.

St.Vincent's Medical Center (NY) -  Drawing on its Roman Catholic heritage, SVCMC's emphasis was on "patient-focused healthcare, with a special mission to provide care for the poor and disenfranchised."

"Respect: The basic dignity of the human person is the guiding principal in all our interactions, policies and procedures.
Integrity: Integrity is the consistency between the Catholic identity we profess and the ways in which we act it is that quality of truthfulness, which fosters trust.
Compassion: Compassion is the way we share deep concern, love and care toward each person.
Excellence: Excellence is our way of demonstrating that we can always be more, always be better."

St. Vincents filed for Chapter 11 bankruptcy earlier this year (which is why there is no link here). Of all of the hospitals where I have worked, never have I felt so grounded in the work I was doing then I did at St. Vincent's.  While part of the healthcare system closed it's doors, other hospitals were sold to different healthcare companies and I think that, with those sales, the mission described above transitioned to that of the purchasing company. 

It was sad really - seeing an organization so dedicated to helping the poor ending up in bankruptcy. I understand it financially - but that doesn't mean I have to like it.

Adventist Healthcare: (MD) "We demonstrate God’s care by improving the health of people and communities through a ministry of physical, mental and spiritual healing."

Johns Hopkins Medicine: (MD) "The mission of Johns Hopkins Medicine is to improve the health of the community and the world by setting the standard of excellence in medical education, research and clinical care. Diverse and inclusive, Johns Hopkins Medicine educates medical students, scientists, health care professionals and the public; conducts biomedical research; and provides patient-centered medicine to prevent, diagnose and treat human illness."

Jefferson Memorial Hospital: (WV) "The mission of West Virginia University Hospitals-East is to improve the health status of Eastern Panhandle residents by providing high-quality health and wellness services, expanding access to care, and participating in the education of healthcare professionals."

Initially when I started reading mission / vision statements, I thought they looked good - both on the walls of the organization or in the marketing brochures that you would see at conferences and grand rounds presentations. But it sometimes seemed like there was a difference between what was written on the walls of the organization or the marketing brochures and the way the care was actually provided to patients and families.

I "got it" about the importance of having a clinical team in line with the mission of the hospital when having family members under the care of the teams at Brigham and Women's Hospital (MA) and Yale New Haven (CT). Of note, the mission of Brigham and Women's Hospital is: "...dedicated to serving the needs of the community.  It is committed to providing the highest quality health care to patients and their families, to expanding the boundaries of medicine through research, and to educating the next generation of health care professionals. Walking into these hospital on a daily basis, you could feel the mission in action - see it in the way people demonstrated care for my family.

Sadly, I sometimes saw the lack of congruence - when professionals would say or do something that was out of line with the mission of the hospital. I started recognizing it in my own work (yes, I mess up too) and in the interactions with (and of) my colleagues and the patients and families in their care. 

"Oh god, he's back here again!" (when referring to a multi-recidvist patient)

"They just want three hots and a cot"

"She's just med seeking"

"He's circling the drain.."

"I don't like working with psych patients"

"If she just took the meds the way she's supposed to.."

To me, the term "congruence" means that if you're going to say things like "I'm sorry, we did everything we could" or "the results of the tests are not good" then you have to reconsider the effects of using phrases like those listed above. I think (my opinion only) the compassion and energy necessary to provide care to patients and families on a daily basis is readily more available to us when we leave out passively judgmental or cynical comments about the patients in our care. 

What does it take to live the mission of the organizations where we work; where we spend as much time (if not more) with our colleagues then our own families and friends?

What would our life be like if we honored the mission of St. Vincent's and "provided care for the poor and disenfranchised" or if you just took a long hard stare at the mission of your own organization and incorporated it into your own life?

Maybe It's About How You Spend Your Day

It was a very sudden death: the husband had been sitting with his wife who reported they had been "just talking about things - life, how our day had gone and what we were going to do tomorrow". After asking her if she wanted him to bring her some tea, he had just fallen to the side and lost consciousness before ever hearing her response. She got up and called 911 and then helped him to the floor and held him until the ambulance came.  

The ambulance transported her husband to our hospital where our ED team had tried unsuccessfully to resuscitate him. 

Almost an hour later, she stood looking lovingly over him while her frail hand held his. "We had just been laughing" she said. "About what?" I asked, curious to know where her thoughts had taken her. "We had been working on a puzzle; he was on one side of the table and I was on the other. I had asked him if he had wanted to switch sides - sometimes we do that to get a fresh look at the puzzle we're working on. But he just laughed and said 'it's not going to help'. There was too much sky and a lot of green - and a lot of flowers."

Then came the question about wanting tea.

I have a friend who's elderly father had spent a warm August afternoon sailing with his best friend in their small 13' Herreshoff sailboat when he had had a sudden heart attack and fallen overboard. Brooks (my friend) said "he was dead before he hit the water, but what a way to go".  Her father's friend who had been sailing with him, pulled him out of the water and tried to resuscitate him but he was gone. He was buried at sea a few days later - their large family yacht anchored a few hundred yards away from their home which overlooked Long Island Sound. After his ashes, an ivy wreath had been dropped into the water and slowly floated away with the current. We all stood quietly on the foredeck of the yacht and watched as the wreath drifted in the direction towards the area where he had been sailing. It was beautiful.

I'm not a big fan of death - especially when there's still so much to do.

But when I think about what would make me most happy in a transition from life to death, it would be to have my final moments fully content in doing something that I love - like sailing on a warm summer afternoon or trying to sort out the perspectives of earth and sky while working on a puzzle with someone who loves me.

Mastering the Art of Coping with Cancer

The phone rings at the desk where I'm sitting: "you should come down here".

"Okay, I'll be there in about 5 minutes, I'm just finishing up." The fun part of my job is that you can't always say what your doing to substantiate the need for extra time, you just have to say when you can get there.  I think 5 minutes is too long, but with the person I am sitting across from it is not enough time.

After 5 minutes, I grab my keys and go downstairs into the ED. In our trauma room there are two slight women (mom and her daughter), both dressed in black, hovering over a man (mom's husband) who is boarded and collared on the guerney. "He's going to be flown out" the Charge Nurse tells me. At the same time comes the confirmation of this by the unit secretary who confirms "the helicopter's going to be here in 25 minutes".

Mom looks extremely tired, like she hasn't had a good night's sleep in weeks and hasn't had a nice, relaxing dinner in quite awhile either. I ask "is there anything I can get for you?" which transcends to the question of whether I can get them a bottle of wine  - "and an IV" (jokes her daughter). They both laugh before quickly getting back down to the seriousness of her husband's illness. "We've been doing this for several years" his wife says. She describes the long battle her husband has with cancer and the uncomfortable routine they have developed with hospitals, physicians and their care. She tells me about the time he was at Hopkins and she had fallen asleep in a chair that they had pulled out for her in the room where he was staying. "In the middle of the night, someone came and wrapped a warm blanket around my shoulders". I suspected she had spent many nights in the hospital where he was - maintaining her vigilance over her husband; her 'true north'. 

"He's a fighter, I've never heard him complain about any of it - any of the symptoms he has or the pain he is in; he just keeps going - his mental strength is amazing and he's such a wonderful man."

She looks carefully at him - consciously lying on the stretcher - boarded and collared after falling and hitting his head. Her daughter steps away from his room with her husband for a few minutes leaving her mother and I speaking quietly about the condition of our patient. "I'm scared" she says quietly, affirming that she has always fought right along with him but this time, something seems different. She has been tightly holding my hand for a minute or two and I just want to give her a huge hug and not let her go and tell her that it's all going to be okay and her husband is going to be fine...

but I can't, so I don't.

Instead, we have a conversation about the art of "knowing" - energetically knowing when it's time  to have the conversations you need to have but for now, this time, just relying on the legacy of your family. "Sometimes the stress in caring for those we love comes and goes - when you feel like you're running out of strength and having trouble navigating everything that's going on, it's okay to rely on the legacy of who you are as a family to pull you through". - Important to rely on the collaborative strength "of all of you because if one person is struggling to cope, together, you can still get through whatever you need to." We discussed the upcoming events that were going on in their family and how the members of her family could help manage the events taking place with her husband on his way to an intensive inpatient stay.

I ask her and her daughter if they need directions to get to the hospital where we are transferring out patient. They laugh - "no, we know how to get there - several different ways...driving backwards".  The strength of their routine was evident - as is the love for for their husband and father.

The helicopter had arrived and they were transitioning him from his ED bed to their stretcher.

I went into the kitchen to get them a few bottles of water for their trip to the hospital. I had asked if they wanted fruit or something to eat on the way: "No" patient's daughter answered, "we're okay - I'm getting really good at forcing her to eat and I'm more then willing to stop along the way if we have to". - I remembered a time my mother and I had gone to eat when my dad was in the hospital in Boston with his autoimmune illness. The food at the hospital was phenomenal and they had some Asparagus soup that we came to love, but the day he was admitted, we sat across from each other trying to figure out how to manage what had happened.

At that time, food was a chore.

I saw the same look in her mother as I had seen in mine over 10 years ago at that restaurant in the Brigham. It didn't matter what was on the plate in front of you - could've been lobster or a great rib eye - it just wouldn't matter, nothing was appealing.

I handed the bottles of water to our patient's daughter. Mom walked forward to kiss her husband before leaving. As she exited the room, she grabbed my hand - "thank you" she said. I gave her a hug "drive safe and try to get some sleep".  Seeing the look in her eyes made me want to just go somewhere quiet in the hospital and have a good cry and say a prayer for them - but (unfortunately), that part of our hospital is still under construction. - So I go to the second best place - a quiet hallway where no one ever goes. 

Leaving the department I look out the door to see if I can see them, but they are gone and all I can see is the group of people in the front lobby watching to see the helicopter take off. 

Here's the top 5 things we've learned as a family in coping with cancer and the other autoimmune illnesses that have come our way:

1. Develop a routine. The more comfortable the routine is, the less you have to worry about external (outside of healthcare, treatment and symptom management) stress getting in your way.

2. Keep track of all of the "tried and failed" medications or care so that you don't have to repeat things that have already been unsuccessful. 

3. If the neighbors ask if they can bring food - don't say "no" - accept all offers because thinking about what to cook for dinner is brain energy better spent at the hospital. 

4. Have a plan, as a family. Know who has the power of attorney and phone numbers and contact information for all physicians, offices and hospitals. Get to know all of the providers who are caring for your loved one and don't hesitate to ask questions about anything from side effects of medications to the prognosis for the illness. 

5. What's the identity of your family? What are the strengths that each of you bring to the table and how can you support each other during stressful times? A little insight into this now will serve you well with any stress that may come your way - use your collaborative strength but also pay attention to those times when there are moments to have tough conversations about decisions that may need to be made. 

 

"Let's Just Think About What We're Doing Here"

My mother used to say "let's just think about what we're doing here" all the time when I was growing up. It had a way of grounding us and making sure we (my brother and I - and yes, sometimes my dad) were making the best decisions based on the information we had available to us. We would frequently consider other ideas and perspectives as well. - I think this was a trait she obtained from working as an ED Nurse for several years, but it has also helped me develop quite an analytical way of thinking.

The other day, I was sitting with an elderly gentleman in the family room of a hospital. He was looking stoic in his jeans and shirt along with a white International Harvester hat he didn't take off. We were discussing his wife's illness and how sick she had become and what our care involved. There were three of us in the room sitting across from him: the charge nurse, our ED Doc and myself.  "Your wife's very sick", the ED Doc said. "I know" her husband replied. He provided an excellent report on the care he provided to her as well as her exercise. He had provided her with her medications and taken her to her appointments and provided her with her physical therapy. Just looking at him, I could tell that there was a very regimented routine they followed to make sure she kept going and doing what her physicians recommended - he was a trooper. 

But her symptoms were such that she needed a much more intensive level of care and needed to be admitted to the hospital, and because of her acuity, there was a need to make decisions about what her treatment would include and how aggressively we would provide care for her if her symptoms were to worsen.

We needed to have a "let's just think about what we're doing here" conversation.

As the physician asked questions about her care, the man answered with the "maintain course and speed" look he had had when he described their routine. But now we needed to have a discussion with him about their plans and 'quality of life'. We came to that critical point in healthcare communication where the physician needed to slow down and communicate with our husband in a way that pulled both of them away from their routines and closer to their hearts so that their difficult discussion could lead to even tougher decisions. - Not an easy task.

Let's just think....

They both spoke a little more about tests that needed to be done and labs he had ordered. He left the room stating he would return when they had more test results and, as it was late at night and change of shift, we also introduced him to our night shift charge nurse who had just received report on his wife's care up to that point. 

After they left, I shut the door behind them and sat down across from him again - just the two of us alone in our family room. 

"I know you love your wife very much and you've worked very hard to take care of her" I said. Under his International Harvester baseball cap, I could see the tears in his eyes as he looked directly at me and then down towards the floor. 

As difficult as those moments often are, I've come to love them for what they tell me about the legacy of family and the relationships we have. We talked a little more and then I left him in the care of our charge nurse and doc who were still deciding on her care in their own "let's just think about what we're doing here" way that helps us all provide better care to the patients and families we serve.

How I Found Out About The Melanoma

In April, I was let go from my job as a clinician at a substance abuse clinic. - "Times were hard" (I was informed) and told that each clinic was laying off one clinician. I was the lucky (or I guess I should say "unlucky").

My boss told me "you'll land on your feet", other friends told me "there's a reason for this" or "when God closes a door, he opens a window". But I didn't know for sure. I was skeptical, tired and 'burnt'. Not being sure what I wanted to do, I put together a resume and thought really hard about what would be my next career endeavor.

I knew that one of the things I wanted to do (while I was looking for a job) was to join a clinical trials program at the NIH. After taking a class in Risk Communication at Johns Hopkins, I had (and still have) developed an interest in pandemic viruses and how treatment issues are communicated within healthcare systems and communities. I thought joining a trial for a vaccine would give me some insight into issues involving the flu (including both the swine flu and the avian flu). And yes, I thought the opportunity to make a little money while learning would also help.

I made it through the first interview as a "healthy volunteer", signed off on some paperwork and was informed I would need to return for a physical. No problem. I scheduled the physical for the following week. 

The physician, the young Dr. Young did a very thorough and comprehensive physical exam (even more thorough then that of my own physician) asking me all sorts of questions about my medical history. She was compassionate, very easy to talk to, asked lots of questions and was very, very thorough. 

When she asked about any marks on my body I was concerned about, I showed her a freckle on my left forearm. "I'm not sure about this" I said. She examined it cautiously and then stated "no, it seems okay" and then added "what about this one on the back of your leg?"

"Who looks at the back of their leg?" I asked, jokingly; but then I realized how serious she was. 

"I don't like the looks of this" she said. And then going through what I have now learned is the ABCD's of dermatology, she stated "it's asymmetrical" and then explained her additional observations of the border, color and differential structure of a mole on the back of my leg (right calf). "I'm really concerned about this and I'd like you to have it checked out before you come back; I'll set up an appointment for you". "Okay", I said, not really knowing very much about dermatology but noting her concern that this was something I needed to look into. 

Three days later, on a Friday morning in July, I had an appointment to see a dermatologist at the National Institute of Health. Dr. Maria Turner (I've since learned) is a phenomenal legend in the science of Dermatology and has been at the National Institute of Health for several years. When she saw the mole she said "you should get this dug out right away". It wasn't so much her tone that accentuated the seriousness of her statements but more the compassionate but urgent look on her face with the direct eye-contact.

Dr. Turner and her team recommended a dermatologist in Frederick MD.
They just happened to have an opening that afternoon (two hours after I left the NIH)

The dermatologist I saw agreed with Dr. Turner's recommendation and just happened to have a cancellation for the appointment that was scheduled right after mine. Forty five minutes later, I was stitched up and ready to leave with my instructions to take care of cleaning the wound and that they would follow up with the results as soon as they had them. 

As I drove home, I experienced one of those "what the heck was that?" anxiety provoking moments. It occurred to me that everything had taken place since 10:00 am that morning and it was now 4:00 ish and I had just had a mole dug out of my leg. I was told to take it easy - and was waiting for test results to see if I had melanoma. "Probably not" I thought, but also realized that a trip north to New England to see my folks would probably help make my life a little easier. So after spending a few more days at home recuperating, I took my bandages and drove to New London, CT to catch the high speed ferry to Block Island - land of grilled swordfish, sweet corn on the cob and fresh tomatoes with basil.

I had a wonderful time - chillin', grillin' and readin'. Mom, Dad and I spent time walking into town, puttering around on their boat, cooking and discussing current events. It was a perfect - albeit foggy - week. 

On day 5, I was at the end of the breakwater in Old Harbor watching the ferries come in and out of the harbor as well as the fishermen who were casting their lines into the surf trying to catch bass. Sitting at the end of the breakwater on some large rocks with my digital camera in hand I realized this was close to a perfect day.

My thinking was disrupted by my cell phone which was buried at the bottom of my camera bag. I reached in to grab it and saw the number of my dermatologist. "I'm afraid I have bad news" she said. The test is positive for melanoma and we need to do more surgery. Because it's on the back of your leg our preference is to have a plastic surgeon do it as they are skilled at closing the wound in a way where there shouldn't be a large scar. We're trying to get ahold of someone now." 

Sitting on that rock at the end of the breakwater, I thought I was going to throw up. We talked a little more and then I hung up. Initially, I thought about going back to the boat and talking to mom (an ED nurse who excels at putting things in perspective with her "let's just think about what we're doing here" conversations which have taken place throughout my entire life). Instead of leaving however, I sat on the breakwater for at least another half hour before heading back. At the time, I needed to have my own "let's just think about where my life is going" moments. I needed to slow down, fall back - regroup - think.

 

This was when the Ah-Ha moment started: I realized as much as it is good to feel like you're in control, sometimes, you're just not. Sometimes, you have no idea where the day is going to take you or the discussions your going to have. You have no idea of who is going to step in the path of your life, your decisions, your heart and how they are going to communicate with you in a way where you (okay - I) 'get it'. And - the best part for me during this time - was the progression of 4 very phenomenal physicians (the last being the plastic surgeon) who were all very talented, highly skilled, articulate and compassionate women who cared for me until the "results are negative" conversation which took place with the plastic surgeon about a month after the initial diagnosis. And these were just my physicians, this list does not include the immense support of family and friends, some of whom are on this list who I haven't spoken with in awhile and enjoyed having the opportunity to connect with because of their friendship, insight and wisdom that just reinforces the fact that I am blessed.

So - enough ranting - but one last thing about these "Ah ha" moments: As a clinician I take great pride in the referrals I make for clients and friends when they need help. I'll admit it, I know really cool people who are really great at what they do. But during this time - this experience, I didn't know anyone and just put my faith in each physician as they referred me from one doc to the next to the next; and I am a much better person having had this out-of-control experience.

Mole was dug out a 2mm
And then again at 5mm
Results were negative at 5mm

No more Melanoma; Life is good.

Lessons learned? - Several:
1. Wear spf 35+ when in the sun
2. Talk to your healthcare providers, ask questions when needed, ask for prognosis, ask for (and accept) referrals to other wizard providers. - Pay attention to the way they communicate with you.
3. Accept help and support from family and friends - especially those who have "been there"
4. Reassess your goals, your values, your heart.
5. Live your life - tomorrow is not guaranteed

Our favorite providers and more information
National Institute of Health
Frederick Dermatology
Dr. Tracey Culbertson
National Cancer Institute - Dermatology Branch
Melanoma.com
Melanoma - Mayo Clinic

http://www.RN-coach.com

Not quite the 3:00am phone call - it was a few hours later

It wasn't the 3:00am phone call that we've been hearing about on the advertisements of politicians seeking office. It was a little later then that - at 6:00am when I got the call.

The call from my mom: "it's your father, he's in the hospital at Brigham and Womens". She tells me that he had started "swooning" (her words) because, like the New England family that we are, it's sometimes easier to navigate the stress or situations by using terminology which has a slightly humorous edge to it.

The fact is that they had been on the boat when he had passed out and hit the deck. Luckily they were at anchor in the small harbor in Cuttyhunk, Massachusetts. Luckily she could arrange for the seaplane to take him back to the mainland once he had regained consciousness a few minutes later and (luckily) the hospital in our hometown thought it would be better to transfer him to "the Brigham".

At that time, he  had not been feeling well but it had taken his Docs awhile to reach (and substantiate) a diagnosis because of the complexity of his symptoms. So as he was transported to the ER at the Brigham, we still had no idea what we were dealing with. To make matters worse, upon entering the Emergency Department, he had 6 seizures and a brainstem stroke which left him in a coma.

When mom called, he had been transferred to the 9th floor "the cancer ICU".

On this day, the drive that usually takes an hour and a half from my apartment just outside of Amherst Massachusetts, took me 45 minutes. One of the parts that was the most memorable for me involved walking down the hall to the elevator banks from the parking garage. It sort of reminded me of the long journeys between terminals in international airports as this hallway seemed to go on forever.

I had finished graduate school in Counseling Psychology two years earlier and was at a very 'cocky' stage in my career. I found myself walking down the hall with the Atom Ant ("...Here I come to save the day!") theme song in my head when it occurred to me that this was not about a patient - not one of my patients anyway; I was walking to see my dad.

My dad was a tall, quiet, executive type guy who used to tell me "Susan, every day you should  have a goal for yourself that you strive to attain". Both he and my mom worked a lot when we were growing up but there was a legacy in our family that remained firmly grounded in helping others and doing the best you could - and then, as my grandmother would say, "try to go a little further".

Walking down the hall, taking off the protective raincoat and draping it over my arm, I felt myself transcend back to the daughter that he needed. I entered the elevator with Physicians, other patients and family members, Nurses and Residents, and pressed the button for the 9th floor. The elevator seemed to get very quiet at that point and I remember thinking that they knew - knew someone I loved was very sick just by the silence that seemed to fall upon all of us as we went up. This hit home even more as I entered the room in the ICU pod. I couldn't help but glance out the window - which looked right down onto the field at Fenway park. We spent a lot of time there when we were kids - back in the days of Yaz, "Tony C." and Carleton Fisk. Sure enough, standing there looking at my dad with all of the wires connected to monitors and IV's, I felt like I was four. And the executive guy that I saw leave the house every morning as we went to school? - this was not that guy. The suit and tie had been replaced by one of those gowns that tie in the back, his hair was grey and he looked much older then he really was.

Standing there looking at him I wondered: where had the time gone?

To make a long story very short, as we pondered what to do and how to care for my dad, we spent a lot of time during the week reviewing his symptoms and illness as well as the care issues we faced. As a family the initial overwhelming shock had transcended into an uncomfortable routine as we spoke about what to do. Do we bring him home and care for him there? What can we expect? We decided that the best we could do was wait until our meeting with the Neuro team and see what they thought regarding his care and his prognosis.

Our meeting with the Neuro team was scheduled for the following Friday morning. As I arrived back in the ICU waiting area around 6:00 am, I was met by the Intensivist who asked "is the rest of your family here?" As I was about to tell her they were still on the way, my mom and brother came around the corner to meet us. "I don't really know how to explain this..." she started (looking towards my mom), "in the middle of the night, your husband regained consciousness and is now fully awake and alert...there is little neurological damage....the team is with him now.....we're waiting to see....prognosis looks good but, of course we have to wait until all of the test results are back.....you'll be able to see him in about 15 minutes..."

It was nothing short of a miracle in our book as we stood looking at the Intensivist - stunned, not knowing whether to laugh or cry but feeling very relieved.

Since that day, that time, Dad has transcended into quite a different guy. As we frequently walk along the road that looks out over the intercoastal waterway near their home in Florida, the "everyday you should have a goal for yourself that you set to attain" statement has given way to the types of fish that are jumping and the best bait to use.  As we tootle (okay - it's a RI word) along in their golf cart seeing what sort of landscaping the neighbors have done or going out to eat at Capalbo's (the best "all-you-can-eat" pizza place on the Gulf Coast) it's hard not to be mindful of the frailty of life, the conversations you need to have when someone you love has an illness or symptoms you can't understand and the way relationships change when you endure a traumatic event such as my dad's illness. Concurrently, it is also easy to remain aware of the quality of care provided at hospitals such as the Brigham and Beth Israel and the way that difficult conversations are often made easier by the provision of care provided by exceptional clinical teams.

Several years later as I sit back to watch the advertisements about the "3:00am phone call", I am more aware of the need to support a healthcare system that can help all of us handle phone calls at any hour and that my  passion about this remains as strong as it did on the day of my mom's call.

Sick of trying to get better...

This article is from the NY Times:

http://www.nytimes.com/2008/02/19/us/19suicide.html?ex=1361163600&en=58482c77cda1fd95&ei=5124&partner=permalink&exprod=permalink

It focuses on the increased rate of suicide for middle-aged individuals which has risen almost 20% since 1999, and speaks to the subjective nature of mental illness, depression and, as my rehab professor used to say, "managing those moments when life gets in the way".

With the mortgage crisis, the healthcare crisis and the struggles that seem to be continuing during these difficult time, this is not anything I can see getting better. I also think that the fast-pace that many of us navigate on a daily basis does not help either. In addition to being distant from the support provided by families, I wonder about what comprises our 'inner-strength'. - The still small voice from within that says 'keep going, it'll be okay' or, like the little engine that could, 'I think I can, I think I can."

My hope on this day, is that support comes soon and the insurance coverage is there.

Emergency Department Registered Nurses

The shortage of Registered Nurses (RN’s) in Emergency Departments throughout the country compromises the expeditious and compassionate delivery of care for patients. In a June 2006 report documenting the “The Future of Emergency Care: Key Findings and Recommendations”, the Institute of Medicine of the National Academies, reported, “Emergency Department visits grew by 26 percent between 1993 and 2003 (Institute of Medicine of the National Academies, June 2006).  The Institute of Medicine (IOM) also indicated “nursing shortages in U.S. hospitals continue to disrupt hospital operations and are detrimental to patient care and safety” (Institute of Medicine of the National Academies, June 2006).  In her testimony to the Subcommittee on Emergency Preparedness, Science, and Technology Committee on Homeland Security, United States House of Representatives on Emergency Care Crisis: A Nation Unprepared for Public Health Disasters, former Emergency Nurses Association President Mary M. Jagim, RN, BSN, CEN, FAEN supports the findings of the I.O.M. and states “because of the unique insight and clinical knowledge of an experienced emergency nurse, the nursing shortfalls constitute a loss of expertise in the system. Nurses are not interchangeable resources. The expertise of a seasoned ED nurse is critical to achieve quality patient outcomes in a dynamic healthcare system that demands competencies for a multitude of situations, including all-hazards mass casualty events” (Jagim, 2006). In addressing this shortage, two factors need to be considered. The first factor is the retention of Nurses presently employed by the hospital. The second factor is the recruitment of qualified Nurses.

Losing Nurses is Costly for Healthcare Organizations

Compassionate patient care is delivered more effectively when clinical teams have been working collaboratively for at least 9 months.  As Nurses transition from hospital to hospital, whether it be because of sign-on bonuses offered or more lucrative salaries or benefits, the once cohesive team becomes fractured and forced to adjust to a new nurse or an agency nurse. Jones (2005) indicated the cost of replacing one RN ranges from “$62,100 and $67,000”. Agency nurses may have abbreviated orientations as they are contracted by the hospital and may not be completely familiar with the units’ policies and procedures before initiating coverage. New RN’s hired by the hospital may transition through a lengthy orientation process before they can begin caring for patients. These issues will increase the cost for the hospital because the ED Director will have to cover the coast of the agency nurse as well as the orientation for the new RN and the salary for an experienced RN assigned to precept the new RN.  These costs also do not include the cost to the hospital for the recruitment of additional nurses.

The Mission of Retaining Nurses

Insight into a hospital’s mission and / or critical success factors may provide Nurses with an idea of the hospital’s goals and expectations related to the delivery of care for patients. Nurses interested in extended employment with hospitals may also take into consideration other issues such as whether the hospital is a “Magnate hospital”, if the hospital has a clinical or professional ladder, and the opportunities for professional growth. Nurses may also assess the professional and clinical reputation of the physician group responsible for coverage in the emergency department.

Team Cohesiveness is a Priority

RNs employed directly by hospitals have faster access and greater familiarity with the hospitals documentation system, policies and procedures, equipment, and medications than Agency nurses presenting to the department to cover staff vacancies. Jagim (2006) affirms, “ED nurses need to be able to receive, send, and access all kinds of patient data on a daily basis. An example is the frequent occurrences of patients arriving at the ED on their own, by ambulance, or as a result of an evacuation from another hospital without any information regarding their medical history. Healthcare professionals should have access to all of the appropriate information: Who is the primary physician? What medicines is the patient taking? What are the vitals? What treatments have already been given?” Nurses employed by the hospital will have more collaborative relationships with physicians and EMS providers thus insuring enhanced communication across levels of care and in fast-paced situations.  For Emergency Departments in high volume areas of the country, this is a critical retention issue. Within the hospital, Nurses will also have a more collaborative relationship with other nurses throughout the hospital that will be beneficial when transitioning patients to lesser levels of care. These collaborative relationships will also help diminish hospital diversions, delays of care or poor transitions for patients.

A cohesive Emergency Department team assists hospitals in maintaining the delivery of compassionate care for patients in a manner that supports the mission and vision of the hospital and the integrity of the clinical team. As teams become more familiar with each other, their personalities and areas of expertise, the delivery of care becomes more seamless and collaborative. Hospitals and Emergency Department administrators need to support nurse retention, as doing so will decrease unnecessary costs for the hospital and enhance patient care.

Our Company: Critical Success Strategies, LLC

The view of psychiatric ED care from here...

In yesterday's Washington Post, we found this article:

http://www.washingtonpost.com/wp-dyn/content/article/2007/01/28/AR2007012801352.html?referrer=google

The numbers and reports speak for themselves: close to 47 million Americans uninsured, 700,000 of whom reside in Maryland. Organizations such as the National Alliance for the Mentally Ill, the Emergency Nurses Association and the American College of Physician Executives are lobbying for changes that just don't appear to be coming soon enough. Pick up the phone and call any of your healthcare providers (including Psychiatrists and therapists), and you'll most likely hear this response "...if this is an emergency, please go to the nearest Emergency Department." Yes Virginia (and DC), Maryland Emergency Departments are crowded too.

The Institute of Medicine (http://www.iom.edu/CMS/3809/16107/35007.aspx) released their 300+ page report on the many issues faced by Emergency Departments across the country last year. This extensive report details the many issues that are faced by Physicians and Nurses on a daily basis when covering the Emergency Departments in the 6000+ hospitals throughout the country.

Needless to say, there's work to be done.

The frustrating part of all of this is that this issue is being treated like the patient in the overcrowded hallway who is difficult to see. "There's no beds available so maybe if we just put him on a guerney....". Families stand next to their loved ones anxiously in hallways while they wait for news...care...anything. As the department becomes more crowded the times (we call them T.I.D.'s - the acronym for 'time-in-department') increase. The physician sees the patients, then writes orders for the RN for tests; ED techs come and draw blood, radiology techs come and take x-rays and then the waiting increases while the results are being completed and consults are taking place. - this is not a process that takes "only minutes".

In the psych area of the Emergency Department, the assessment process can take additional hours. I once assessed an 8 y/o who was feeling suicidal. This was her second visit to the ED in a week. She was having a difficult time managing her feelings and had a plan on how she would end her life. This second visit was exacerbated by the sniper shootings that were happening in the Washington DC area at the time. Her school had been placed on "lock-down" and all of the students were placed in the cafeteria. Imagine being in a crowded, noisy cafeteria for hours with several other children in a stressful situation. She went home and told her parents that she wanted to kill herself and they brought her to the ER.

The medical evaluation (including all of the necessary labs and tests) took place; and then our psych evaluation followed by an extensive discussion with her parents about their ability to keep their daughter safe. As they were concerned that they would not be able to do so (and because this was her second visit in a short amount of time), we decided that the safe thing would be to refer the patient to a child psychiatric unit at a hospital that was several miles from our ER. (this meant that transfering the patient to the hospital would involve a trip on the beltway) for the Ambulance.

More time; more wait. The paperwork to transfer the patient needed to be completed, the registration and subsequent precertification with the insurance company would need to take place, the paperwork would need to be faxed to the accepting hospital and then reviewed with their attending physician (who would need to be woken up) and then, once all of the paperwork had been accepted, the call would have to be placed to the ambulance company to find transportation for the patient.

It was close to 2:00am when most of the process was completed and all we would need to do is call the ambulance and arrange for transportation.

This was when we were approached by the parents who asked that we "wait until morning to transfer the patient". - "This is too much for her" mom said.

She was right. Her daughter woke up to go to school early that morning, she was in a noisy school, followed by a tough conversation with them about how she wanted to end her life which lead to a trip to the Emergency Department. The wait for a bed, the evaluation by the Doc and the RN, the multitude of questions that I had asked her about her ability to be safe (not to mention the tears that followed as a result of the intensity of the discussion)..it had been a long day for her.

As the ER was quieting down a little, we met as a team to discuss the issue and then followed up with the Administrator on call to determine if she could buy some time in our ER and get a little sleep before being transferred to an inpatient psychiatric unit where the multitude of questions and evaluations would start all over again.

"This isn't the Hilton" - okay - we expected this because, Emergency Departments are busy (we mentioned this before right?).

At the end of the collaborative discussion, we advocated for our little patient and when I left her, one my colleagues had taken the oversized bear out of our waiting area and placed it in a chair that was at eye-level to where our patient slept soundly on a guerney in a quiet area of our ED. Mom, coverred in the warm blanket provided to her, watched over her daughter until the morning when she would be transferred out around 7:00am.

I wish that every congressman, congresswoman, senator, advocate and critic could see what we see every day in Emergency Departments.

What I know for sure is that this is a critical issue demanding the same attentive care that we all strive to provide for our patients every hour of every day they are with us.                          

                  Labels:                       ED,                       healthcare management,                       nurse,                       patient,                       patient care,                       physician,                       psych assessment,                       washington post                         

ED Nurses and workplace violence

I found this article on the CNN website and have been obsessing about it:
ER Nurses and Workplace violence

The best place to start is with the last line "this is what we do, we care about people".

In the interest of full disclosure: Part of my consultative practice involves training ED nurses to assist them with developing the skills to manage workplace violence. I have many friends who are ER nurses and administrators as well as my mom who is an ED RN. I know from working collaboratively with my ED teams (I've worked in three Emergency Departments during my career) that if you had all of them in a room together, you would probably hear the same thing - that they love their careers and that this is "what we do".

But that doesn't negate the fact that I am concerned for them and the challenges they face in their careers everyday. We know the statistics: that there's 46 million people in this country who do not have health insurance. That there is a shortage of Nurses and healthcare professionals throughout the country and that the 6000 hospitals in the United States are facing challenges that are difficult to manage. And with all of the criticism which is taking place about the healthcare system, I sometimes think that we forget to consider the nurses, techs, physicians and healthcare professionals who put their lives on the line to save ours.

Additionally, there's a few things that I think are important to remember about Emergency Departments (ED's):
1. ED's never close - it's not like the TV series 'ER' where you have fun and excitement for an hour and then it's over; 'real life' ED's are open all the time and often very busy.
2. Not only are ED's really busy, but how many times have you called the number of a healthcare provider to hear: "if this is an Emergency, please go to your nearest ER." Appropriate? - yes, but what is the definition of 'emergent' care? (yep, I know, it's not something you can define in the length of an answering machine message). And if you think of any time where you may have had to drive someone to an ER or call 911, think about how anxious you were when having to make the call and then wait for the ambulance to come. This anxiety may lead to fear (related to not knowing what to expect or what is causing the symptoms your loved one is having) or anger (related to, or exacerbated by, the frustration and anxiety of not knowing what to expect or what is causing the symptoms your loved one is having).

Even if the visit to the Emergency department is precipitated by acts of violence, there are still emotions to consider - most, if not all, are a result of not knowing what to expect, not being in control or not knowing how to navigate a healthcare environment.

It's like that song by Morris Albert: "feelings...nothing more than...feelings..."

Then you arrive at the ER - it's busy, somewhat noisy and there's a lot of people talking using terminology that may not be familiar to you. In these fast-paced, critical situations, you may also have to ask questions about terms you may not understand, but the providers treating your loved one, who witness your feelings and emotions, have to also adjust their own defenses (which protect them in the work they do every day), slow down and explain the information you need to hear in a manner in which will assist you with having to have some potentially difficult conversations.

Think of what we sometimes hear:
"I'm sorry, they're not going to make it through the night..."
"We think that surgery is necessary and should happen as quickly as possible.."
"We did everything we could...I'm sorry..."

I wonder about this question when thinking about our healthcare system - have we done everything we can? Do we owe it to the professionals working in healthcare to support them and make the system of care in our country better?

While the article states that "assaults on nurses are more of a product of a violent society, where mass shootings are no longer rare, than a nursing shortage", there is a lot to consider when developing safer environments for our healthcare professionals.

These considerations about creating safe environments potentially include difficult conversations about:

1. The importance of retaining our healthcare teams and supporting them by debriefing our teams after experiencing difficult or critical cases or multiple codes (even if it is an informal debriefing and takes only 5 - 15 minutes).
2. New nurses coming into the field of healthcare who have an abundance of knowledge but may not yet have the interpersonal defenses to cope with the experiences they have in emergency or acute care environments.
3. Training to assist healthcare teams with skills to triage, assess and communicate with patients and their families who may present with primary or secondary behavioral health symptoms (including addictions) in a manner which insures safety for the patients, their families and clinical teams.
4. Collaborative communication across levels of care so that patients can transition through emergency departments quickly to the most appropriate levels of care taking into consideration the differences in communication styles and defenses for each clinical team.
5. The reduction of overstimulation that emergency departments have as well as the physical layout of the department.

While I think that some of these coversations are long overdue, I believe the more critical issue is developing a scope of practice which addresses and monitors these issues so that we can retain our experienced clinical teams, support our healthcare system and provide better care for patients and their families.

Need help with developing and implementing this practice?
Contact us at Critical Success Strategies, LLC