Wednesday, October 15, 2014

An excellent op-ed from a Minion in lovely EnZedd. . .

This is what we all should be worried about.


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.

Sunday, October 12, 2014

In Which Jo Has Doubts About Her Floor.


Some of you longer-term minions might remember when I bought Casa DogHair and renovated the bathroom. The shortest version, for those of you who haven't sobered up yet, is this:

The people who owned CDH before me were both of some size. They were also not good with maintenance. This led to the bathroom being entirely rotted out in vital areas, which in turn led to Then Boyfriend and I redoing it.

I should mention here that Then Boyfriend had a weird work schedule and I was working all the time, so I had very little input into the construction. I helped with demo, tiled the floor, and that was it.

So when I stepped through the bathroom floor a few months ago, it came as a bit of a surprise. TB had told me he knew what he was doing; in fact, I knew he had worked construction in the past. So I trusted that he knew how to install a bathroom floor, make the shower water-tight, all that stuff.

Instead, what I found was un-taped cement board in the shower that had been waterproofed on the wrong side, weird joints that weren't water-tight, and a floor that. . . .well.

Normally when one installs a tile floor, one lays a sheet of plywood down and fastens it to the joists. This provides a stable surface for what's to come after. Then, one lays a quarter-inch-thick layer of thinset mortar down and uses that to bed cement board. It's important, when you're laying tile, to have a deflection-free (no bouncing), solid (won't shift laterally), independent (not screwed to the joists) surface for the whole shebang. Plywood screwed to joists is layer one. Mortar-bedded cement board, screwed to the plywood bur not to the joists, is layer two. Properly done, the resulting monolithic surface should last a lifetime.

He had laid half-inch cement board over a vapor barrier and nailed it to the joists. There is so, so much wrong with this that I can't even. I had to liberate a fair two gallons of water from under the floor, atop the vapor barrier, where the weird seams had leaked.

Here's the deal: demo of a properly-installed tile floor of this size ought to take a solid day or day and a half of work. It took me forty-five minutes, and I didn't even break a sweat.

After I demo'ed the floor, I began to get the willies about the shower, so I started peeling tile off of the walls with my bare hands, no joke no kidding, and the whole project got exponentially bigger in about ten minutes. Shower tile should not be removable with one's bare hands. 

But it was and it was and here we are, with a plywood floor barely tacked down and shower walls covered in plastic.

Which brings me to the floor. All of the preparation for laying tile will result in a floor that's at least 3/4 inch higher than the floor outside the bathroom door.

The Boyfiend, who actually *does* know how to do this, has done it before, and is doing it right this time, floated the idea of lowering the joists under the bathroom to give us sufficient clearance to have a seamless transition between the wood floors outside the bathroom and the future tile within. Over dinner last night, he and his brother The Psychopath debated the various ways this could be done, with The Psychopath insisting in a querulous voice that we'd have to pull the tub (find me four strong and patient men and a space warp, dear; that tub is wider than the doorway) and jack up various bits and bobs of the foundation.

Boyfiend insists this is not a big deal. I have my doubts about that. As I told him last night, when I hear a man say "It's no big deal; it'll work out fine" I know that I'm gonna need three hundred bucks and a course of antibiotics, stat.

So I started thinking of alternatives and came up with a roll of rubber flooring in a coin pattern. It's exactly the same thing that Daniel used over at Manhattan Nest a gazillion years ago. It's cheap, totally waterproof, and there will be no seams.

And it's thin enough that we won't have to lower any joists or do any other major structural work.

Boyfiend is still snoring away, but I plan to hit him with this idea once he's up and has had some coffee. And we shall see.