Wednesday, October 15, 2014

Conclusions.**

Thanks to the Virally-Knowledgable Minion who pointed out that I made an error by referring to Ebola as EBV. That is Epstein-Barr virus, not Ebola. As you can see from her/his comment below, Ebola is referred to as EVD or EHF. That error's now been fixed. Thanks very much for that correction, VKM! I knew there was something off about my abbreviation, but I couldn't think of what and (of course) didn't bother to check. Der.

The whole EbolaPocalypse is wearing on everybody's nerves.

I have friends who work in Dallas. A couple work at Presbyterian there. And holy shit, are things bad there. Last I heard, surgeries had been cancelled and the ED was turning away ambulances. I don't know what's happened in the last twenty-four hours, but that's what I heard on Monday.

Here's what's happened at the hospital so far, for those of you who have either been under a rock, across the uncharted oceans, or simply hiding under the covers:

A symptomatic patient, Thomas Eric Duncan, showed up at Texas Health Presbyterian Hospital (Presby) in late September. He had a fever and abdominal cramps, and told the intake nurse that he'd come from Liberia, but was sent home with antibiotics. He was later readmitted with bloody diarrhea and projectile vomiting and put in isolation.

At first, Presby officials said that he had lied on his intake form; that he'd said he hadn't been in Liberia. That turned out not to be true.

Then, Presby officials said that the intake nurse had not communicated Mr. Duncan's travel history to anybody else on the health care team. That story stood for a couple of days until some bright person pointed out that travel history is right there in the electronic medical record for anybody to see, and obviously warn't nobody checkin' nohow.

Then they said that he'd been isolated immediately. That story stood until today, when a nurse at the Presby ER said no, he'd actually (during his second admission) been sitting in a common area for as long as seven hours.

Then he died. But not until after getting dialysis and being intubated, both of which the WHO says won't do shit to prolong life and *will* do a lot to spread aerosolized virus or increase the risk of bodily fluid exposure.

And, as it turns out, the nurses at Presby who cared for him spent two days in standard isolation gear (flimsy plastic gown to the knee, goggles and mask if you're lucky, gloves, booties if you can scrounge some up) and also had other patient assignments during the time that they cared for him.

Of course, the CDC said the minute the first nurse came down with the virus, that there must've been a breach in isolation protocol on her part.

But then it turned out that holy crap, the hospital had waited until final results of viral testing from the CDC had come back to get their workers into proper gear and limit their patient-care assignments. The preliminary positives apparently weren't enough, combined with the poor man's travel history, to alarm the administration. So it wasn't so much a breach of protocol on the RNs part as it was sending a nurse into a forest fire with a bladder full of piss and no backup. Nurses were cobbling together whatever they could in an attempt to replicate proper isolation gear. They were borrowing from other departments and MacGyvering stuff for two days.

Now a *second* nurse has come down with Ebola, and she travelled from Dallas to Cleveland and back in a state of as-yet-undetermined contagiousness. I got nothin' to say about that except holy shit what a . . . .wait, no. I can't judge. Because if she'd been told she wasn't contagious without symptoms, and her movements weren't restricted, then. . . .? I don't know what to think about this part of the story, because, if it's like the rest of the story, there's more and different facts to come.

So. What conclusions can we draw from this?

Conclusion the first: The first reaction on the part of everydamnbody has been to blame the nurses. From the first inkling that Mr. Duncan's diagnosis was missed to the news that a second nurse was infected, the director of the CDC and the administration of Presbyterian Dallas have pointed to the RNs as the weak links in a chain.

I'm sorry, guys (because they are all, frankly, guys, and NOT nurses): in order for a fuckup of this magnitude to happen, a number of links in your chain of failsafes have to break. It doesn't matter if you have a "health care team" if members of that team only see each other in the bathroom and when they're punching in. People have to communicate, yes, but they have to be given the opportunity to communicate, which means proper staffing levels and backup when it's needed.

For one, nobody noticed the travel history when it was submitted the first time. That means that the ER staff was either understaffed or slammed, or both, and/or that the intake nurse never got a chance to communicate face-to-face with the rest of "her team." So you had a team in name only, screenings in name only, and procedures in name only.

Conclusion the second: Whoever had the job of preparing the Dallas area (and my area, come to that) as a whole for Ebola did a piss-poor job. The nurses I work with have been talking about the probability of caring for an EVD-infected patient since July, when it became apparent that the outbreak was getting out of hand overseas. ER nurses I work with have been wondering what, exactly, to do for protective gear and isolation facilities, since not a lot of hospitals have more than curtained cubicles in the E R. We do not even have an international airport in this area. What must it have been like in the breakrooms in Dallas?

To give you some idea, one of my besties works at a large academic medical facility in the Dallas area. It's the sort of place you take gunshot victims or people who've been hit with a chemical contaminant or folks who've been bitten in half by a llama. She told me yesterday that her facility's prep for Ebola (and keep in mind that this place has a busy ER in a highly international area) has consisted of one streaming video and a lot of assurances from administration that they're working as fast as they can on a protocol.

Guess what, Administrators of the World? The CDC and WHO and MSF already have protocols in place. All you have to do is devote the time to learning them and the money to proper materials.

Conclusion the third: If you are a nurse anywhere in Texas, you are screwed to the wall. You might wonder why the nurses at Presby who spoke out are being protected by the largest nursing union in the US. It's because you're told, as a nurse, that if you say anything negative about something that happens at your facility, you will be fired. Period, full stop, do not pass go.

A couple of years ago, somebody got mugged in our parking garage. A nurse I worked with put it up on social media that she no longer felt safe in that garage, and wondered why we didn't have better lighting. Two weeks later, she was gone. Fired. For a med error that had happened months before, and for which she had received no prior counseling. All totally fine and legal in Texas, kids.

Imagine what it must be like for the Presby nurses who were sent home, day after day, to their families and dogs and cats and knew what they'd been in contact with. They can't say boo for fear of being fired and placed on the informal blacklist that exists in this state.

Conclusion the fourth: Texas nurses need a union. Yes, unions tend toward the bloated and bureaucratic. Yes, unions sometimes do more harm than good. Yes, yes, yes, I know all the arguments.

But right now? The nurses in this state are being hung out to dry by their bosses, and nobody's getting upset, except in a very low-key, please-don't-fire-me kind of way.

If I had to care for a patient with Ebola tomorrow, I would have no appropriate protective gear. I would also have no way to refuse the assignment (not that I would; I'd pull up my big-girl panties and pray like hell). I would have no way to protest that I was taking care of the patient without proper safeguards in place. The most I could do would be fill out an incident report after the fact and hope that it got to somebody who gave a good goddamn.

They say you can't be fired for calling safe harbor here, but I've seen it happen many times. And there's no way to register that you're nursing under duress. None.

Unions add a little muscle to the arguments that nurses make. It would be nice, for once, not to feel like I'm stepping out on a tightrope over a windy canyon full of hungry alligators, naked, with a bad case of chiggers on my ankles. I would like some fucking backup, please; a little bit of muscle that I could use to enforce the staffing ratios and protocols that my administrators brag about on promotional materials.

I have no problem at all taking care of somebody with Ebola. I don't think it's necessarily the best idea to have such a disseminated system of care; perhaps we should look into certain hospitals specializing the way Emory and Nebraska do.

However, if it comes down to it, I am more than happy to do it. I did not sign up for this job because I thought it would be glamorous or easy.

All I want is a little consideration, a little preparation, and a smidgen of concern for my safety. From what I've seen of how things have been handled up to this point, I doubt I'd get any of that.

**It occurs to me that this is the most bolded, italicized, and screeching post ever posted in the posting history of this here blog. Sorry 'bout that, y'all.

17 comments:

PhysioProffe said...

Thanks for posting this. It clarifies a lot.

Anonymous said...

Thank you for your post. I was hoping that I was over thinking blame the nurses vibe I was getting from all of this. Good to know what the nurses in the area are really seeing and saying. AZ is similar in its talk and you're fired, blacklist style of nursing. Or at least it was. I'm glad I work in a slightly friendlier state now, though it could be argued that you just have to go through more layers of shit before you get to the true deal. Stay safe down there.

-rnmon

gela said...

Ahmen sista and well said!

Jacqueline Bennetts said...

I have been watching the nurse bashing from here in NZ with horror. I wish I coud help. Our union is all those things you said but thank goodness we ghave it. I hope to hell they are working on a response (I might send a question to our union president later actually now you ade me think of it). I have been reading Madness who has hit the nail on the head when she says the Planning for this amounts to a piece of paper in a disater policy manual and that to me sound like so much toilet paper for all the use it would be.
Suzanne Gordon who I think is marvellous has also come out critising the nurse bashing. This articale is good
http://suzannecgordon.com/new-oped-on-cultural-and-computer-issues-in-dallas-ebola-cases/
Take care and stay safe.
Jacqui in Sunny Christchurch

RehabRN said...

Scary, scary, scary.

How many lives will be lost before we realize we have to talk to each other and trust one another?

I talked to an infectious disease MD about this the other day. His thoughts: OMG I will never sleep again if that happens.

I also work with this guy, AND I trust him, and he does the same with me. I thank my lucky stars every day, too.

I'll be praying that this plague doesn't spread anymore.

Anonymous said...

When I heard in the news that the nurse who contracted Ebola in Dallas was relatively new and was not experienced, I thought here you go.... blaming the nurse. I teach at nursing school as an instructor and we always talk about preparing students to be aware and interested in political climate and be able to use politics to get the important message across, but I think we are still so conservative compared to different group of professionals with unions. I live in Canada, and I heard in radio that Canada is ready for Ebola because we are experienced with SARS. I thought, really... SARS!!! Ebola is completely different caliber than SARS. I am very very worry about how prepared CANADA is for Ebola.

Lace said...

Stay safe! I am new to the profession. Watching the nurses being treated like this is absolutely sickening. I'm praying like hell.
Lacy

Anonymous said...

I don't expect you to let this pass moderation and that's okay - I am a virologist and someone passed me your link, just wanted to give you a head's up in case your blog spreads further

Don't refer to Ebola as EBV as you do in your second point, EBV is Epstein-Barr Virus, the virus responsible for mono. The strain of Ebola virus causing the current outbreak is abbreviated as EBOV, with the disease referred to as Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF).

Kaci R. said...

Thank you!

I agree with you wholeheartedly. It is absolutely maddening that the knee-jerk reaction is to blame the nurse. Then again, it's not at all surprising.

I have never had any training regarding precautions for Ebola. Not in nursing school, not even in my nurse practitioner program. As an ER nurse of 4+ years, I also know the harsh realities of being understaffed, underprepared. I could promise you that on any given day, we would not be adequately prepared for an Ebola breakout. Honestly, which hospital in the U.S. would be prior to this outbreak?

To blame one entity - the nurse - is just asinine and cowardly. It's almost always a SYSTEM failure of this magnitude.

Thanks for sharing.

Kathi McClenney said...

My thanks also for your post, great job.

JEN said...

Very well said.

Rosanna said...

Because I've been there/done that (HA!)............ how about a large, hand-cast, oval bronze *plaque*, Jo, for the Front Entrances of select large Hospitals in the country that, first --curved around the top-- says in Latin:

"What will OTHER people think??!!"

............ then, secondly --curved around the bottom of the bronze plaque-- says in Latin:

"You didn't TELL anybody, did you??!!"

(Latin always just somehow makes it so much *nicer*, don't you think??!! Haha!!)


Yours is a very realistic & clear-eyed, yet c.o.m.p.a.s.s.i.o.n.a.t.e. wisdom (as usual!!); and I think Briana Aguirre, R.N., will never know how many LIVES she will have indirectly SAVED............ because of her authenticity, credibility, honesty, and her extraordinary personal courage. (The DAY of Briana Aguirre's National TV Interview on Thursday, October 16th, one of our local Medical Center VPs came out with this statement, "From a personnel perspective, it's all about ensuring Hospital ataff are comfortable and confident in what they are doing"............ then the VP discussed Ebola-specific simulations, exercises, and other hands-on In-Service Programs.)

Thank you for this super, *super* post, Jo.

Kaye said...
This comment has been removed by the author.
Kaye said...

Unions have your back when the management wants to fire you. when you are in a union, you have rights and management has to follow a fair process. It is a pain in the ass for management but unions are not just about getting more money for employees, it's about just this kind of stuff - workplace grievances, work conditions.

LivefromBoston said...

Excellent post, thank you.

Aviana said...

How many people are going to die before the blame game stops and fixing the problem starts. Training should have started years ago, not tomorrow or a month from now. Retired Critical Care RN

amy said...

What's the informal blacklist?