HIGHER PRIORITY ACCESS TO THE EMERGENCY DOCTOR AND TREATMENT TO MITIGATE THE NEEDLESS DEHUMANIZING SUFFERING, IN SEVERE PAIN.
In this blog I also question the morals, ethics and the rational fog ever present and unquestioned in our Emergency Departments.
There are groups of people who should know that civility is often pregnant with hypocrisy and comes loaded with a lot of baggage: one such group is the designate authority in our emergencies: doctors. And frankly it should not stun anyone in the health care continuum if I happen to point my finger at them as the most responsible over all other groups.
COMPASSIONISM, MORALS AND ETHICS, AND THE RATIONAL FOG:
As doctors and nurses and paramedics and their respective managers and executives (and their respective professional associations and organizations are very well aware), they all know and they all in their turns, have observed on many, many occasions, that a non-pain-patient rated/designated "CTAS2" (CANADIAN TRIAGE ACUITY SCALE level 2= "CTAS 2”- one priority level below the immediately life threatening) waited for 5/6 hours or more, for access to the emergency doctor and treatment with no clinical deleterious effects! But their mutual patient-in-severe-pain is forced to wait these same 5/6 or more hours in the queue, UNTILL the non-pain-patient gets the privilege of accessing the emergency doctor first!!
Let us belabour this daily reality a little:
So the non-pain-patient frequently waited for 5/6 hours in no pain and suffered no deleterious effects;
BUT the severe-pain-patient waited and waits in severe unrelenting and increasing dehumanizing pain for the same 5/6 hours, and most likely another one hour or more for the next available bed, for her turn to access the doctor and treatment. And that’s assuming that in the interim no CTAS2/3 non-pain-patient presents at triage.
SO, WHILE THEY ALL INTELLECTUALLY KNOW THAT PAIN IS MERCILESSLEY UNDER TREATED, THEY ARE EMOTIONALLY, SPIRITUALLY, MORALLY, AND ETHICALLY, BLINCKERED IF NOT UNCONSCOUS TO THE DISONANCE IN THE WAY THE CTAS GUIDELINES ARE CURRENTLY APPLIED IN OUR EMERGENCY DEPARTMENTS TO FAVOUR THE NON-PAIN-PATIENT AND DEHUMINIZE THE PATIENT-IN-SEVERE-PAIN.
Whether or not an 89 year old patient`s history of dementia and or other chronic diseases competes with her life expectancy is open to debate as to the aggressiveness of treatment (ageism?). But the same patient in severe pain afforded unnecessarily delayed access to the emergency doctor for many hours, to suffer needlessly is immoral and unethical and not yet criminal victimization; COMPASSIONISM in fact.
A little introspection and basic human compassion should tell anyone that the values and situational privileges must be REVERSED....the reversed queue. The “FLOATING CTAS LEVEL F” ( or as a favourite doctor offered: “ctas2p”; p for pain”) IS THE HIGHER PRIORITY ACCESS TO THE ER. DOCTOR AND CARE to be assigned to patients in medical or traumatic severe pain.
So where are the emergency doctors and the nurses and the ambulance services who should be advocating for these disadvantaged patients? Are we that expect compassion, to accept that the reality of their severe pain is not evocative enough?
I’m describing the condemnation of these disadvantaged patients!! Since peer review does not exist, or, to be fair to the few, of little influence, is this behaviour not then representative of an ideology overwhelmingly subscribed to in our emergency departments and emergency services and in nursing!? But I offer you a certain truth: Just as any ideology is often racist, ageist, sexist and otherwise pregnant with biases, so is THIS ideology COMPASSIONIST. And the"compassionist” should bear the same stigma, shame and consequences as the perpetrator and the culpable, not only professionally but much more broadly in our society just like any other "–ISM". Animal lovers treat their pets better don`t they? And our society protects their pets.
There is of course the aspect of the “herd mentality” characteristic not only of the innocent and seemingly innocent but also of the insensate and inhuman. The herd mentality is very vulnerable to ideology. The awareness of this is instinctively known in any group dynamic.
In our emergency departments the prevailing ideology is COMPASSIONISM toward a select group of our mutual patients presenting in severe pain; Compounded by AGEISM and INCAPACITY: the classic victim is the elderly and the nursing home patient with dementia or other history.
The emergency doctors and their Chiefs are the system in each hospital; the “system” they often blame and dump on as their excuse, the Ministry of Health, is not to blame. Lack of compassion has nothing whatever to do with cut backs in Health Care. Doctors are the higher designated authorities in the health care continuum. Doctors oversee the application of the CTAS GUIDELINES: Therefore they are the compassionist overseeing the compassionism in our emergency departments: The responsible and the culpable. And where have the Nursing Organizations and the Ambulance Services been?
I recently spoke to two doctors who practice in emergency medicine, separately. Both of coarse agreed (as other doctors before them did) that pain is under treated; not an intellectual debate. I do not want to devalue this widely held, empirically based truth. But this practice of UNDER TREATING OF SEVERE PAIN in our emergency departments is the easiest truth to acknowledge by all doctors; and I always end up wondering if these doctors (and nurses and paramedics and respective supervision and administrators) realize the weight of what they are acknowledging: just how subordinate or foreign can human virtues such as morals, ethics and HELLO-COMPASSION, be!
So, calling all Emergency ambulance Services, when is this fever going to exhaust you? Are you so overwhelmingly desensitized that you are numbed to the excuses for your much diminished humanity? Is it simply that you are overwhelmed by these designated authorities? There may very well be a specific ambulance service whose managers may deserve my apology, but my intent is very broad: The Emergency Ambulance Services are much to blame and should own up to it as well! In my view, they are willingly complicit participants in the dehumanization of many of their mutual patients presenting in severe pain, even if by proxy because of their paramedics’ fear, uncertain knowledge, and lack of confidence, diminished resolve as to what they observe in their patient, essentially desensitized if not dehumanized as the paramedic care givers on the road and until their mutual patient is transferred onto the hospital bed. Much to be ashamed of!
These professionals all know what severe pain is, looks like in another human being, and feels like, the measure of which a family member may have experienced. And they had their share of patients whose severe pain was not ameliorated or mitigated against by any significant measure UNTIL their mutual patient had access to the emergency doctor. And they also know that for patients in severe pain, oral analgesia and the standing order for iv. pain relief to be administered by level 3 paramedics are the equivalent of sugar pills. Although these may suffice for a “broken baby finger”, and this pseudo treatment is limited to trauma patients only: An interesting construct.
THE EQUALITY OF QUALITY TREATMENT RESULT:
Learned medical professionals often observe a constant weakness, in the context of frequent hospital misadventures or adverse events, “that we often look at or for what confirms our decisions”. The CTAS Guidelines make it easy to cover what most do not want to uncover; that is the misconceptions and perhaps, lies about themselves as good compassionate, moral individuals, essentially their diminished humanity and about the uncompassionate milieu they work in: precisely why I dismiss the current application of Triage guidelines as suspect ideology.
Ofload Delay: To those among us who are not familiar with the phrase "Ofload Delay", it is simply the term that is used in Ontario and elsewhere in Canada for no available beds in our Emergency Departments--for waiting in the queue to be seen by a doctor.
This Ofload Delay phenomenon, howerver labelled, is ever present and current throughout the western world; around which Hospital Administrators and Government Heath Departments play much politics.
And so you’ll know, non-pain patients have waited for 5/6 or more hours on many, many occasions with no deleterious deterioration: this is precisely the clinical knowledge that hospitals and the medical advisors to our government collectively, disabuse and exploit in their respective politicized blame games for the offload delay mess; bottlenecks versus rise in taxes: A sort of convenient collusion; an agreed upon duelling turf! This by itself is a secrete, well kept from the public and the wilfully ignorant and otherwise blind professionals such as nurses, paramedics and of course doctors.However, the pervasive and perverse lack of compassion (or compasionism), in spite of their knowledge that empirically pain is horrifically under treated in our emergencies, IS NOT in policy, in practice, officially and administratively acknowledged and is in fact ignored. So just to be clear, they disabuse and exploit their clinical observations to prop up and underpin and fence the turf of offload delay upon which they currently duel and with no hint of guilt; ruthlessly, blame the needless suffering in severe pain by many of their mutual patients, on offload delay: MONEY!
Currently, as an Ontario based paramedic, whenever I bring a patient immobilized on a backboard to the emergency department, at whatever CTAS Level -the reason for the immobolization to protect the spine is in reality nearly always "just in case"-this privileged patient gets access to the ER doctor within THE HOUR OF BEING TRIAGED: this policy adopted by all hospitals, was instituted twelve or fifteen years ago: this is the same kind of hospitals’ administrative issuance of new policy directives of professional standard of practice minimums [the “CTAS F=HIGHER PRIORITY ACCESS TO ER DOCTOR AND CARE FOR PATIENTS IN SEVERE PAIN] I have been advocating for! PRECISELY!
THE RATIONAL FOG...
is not subtle. Whereas it’s a given that the patient on the backboard is 99.99% spinal injury free and not in pain beyond their discomfort and mostly presenting with mild and less frequently with moderate symptoms, and whereas this has been known for the last 15 years with no changes, the patient on the backboard gets access to the ER doctor within the hour..........BUT..our previous patient, not immobilized on a backboard, IN SEVERE PAIN,WILL BE DISAVANTAGED AND CONDEMNED to suffer behind this patient in the queue, and further back still, behind the CTAS 2 non-pain-patient for too many hours!
Pray for the elderly or nursing home patient. And don’t they all know that 100% of their patients in severe pain remain in severe pain and often enough, made much worse by the patient’s confusion. A little introspection with a little common sense should lead anyone to conclude that this inhuman behaviour has everything to do with “triage priorities” and nothing whatever to do with offload delay, just as racism has nothing to do with "offload employment"-pun intended. It’s everything to do with administrative policy directives, predicated on owning up to a lot of shame, and nothing to do with the convenience of offload/wait- times politics and money.
NO FUDGE:
I never did and I will not spend any energy towards efforts to “try to change anyone’s attitude (or to) force them to be more compassionate” in our emergency departments. I am asking for help to bring the gravitas of NUMBERS to advocate for behavioural stipulations in the form of higher priority access to the many of (“their mutual”) disadvantaged patients in our emergency departments; simple administrative policy directives such as the ones hospitals and any institution fire off almost on a daily basis: A simple tweaking of the current misguided application of the CTAS Guidelines. I am not in the attitude expunging business; I subscribe to the business of reducing the horrific consequences of professional and managerial, and executive arrogance, evasion and avoidance, and wilful ignorance.
Pain is easily qualified as subjective. But who is to deny, and subsequently remain credible and maintain ones’ recognized gravitas, that objectivity comes loaded with biases and –ISMS? And yet empirically it’s been long established intellectually that pain is seriously under treated in this country (and what of the morally and ethically questionable practices in our emergency departments which I would highlight as at least as BRANDED indifference). What emotional comfort can a lesser mortal get from this medical professional objectivity, pregnant as it is? Where has this objectivity that can cite the empirically-established, been delivered as a mindful, heartfelt, mitigating factor to their mutual patients who suffered in severe pain?
“Pain never killed anyone”. The last person to tell me this is a supervisor in an Ambulance Service. But I’m sure my fellow Canadian reader, will recall last December, 2007 at Brampton hospital emergency ( in Ontario), a patient presented with “severe stomach pains”...waited for 12 hours”. This patient died from “pancreatitis complications”. Need I point out that “Complications” is the euphemism that medical institutions use for screwing up. Would a higher priority access to the ER doctor and care not made a difference if those twelve hours of dehumanizing severe pain where reduced to twelve, twenty four or thirty six minutes!? I’m no doctor, but I cannot accept that SIMPLE COMPASSION WOULD NOT HAVE SAVED THE MAN’S LIFE; THE MILLEUE OF COMPASSIONISM KEPT THE DOCTOR AWAY!
A Policy of higher priority access to the Emergency Doctor, ALONE, if indeed not COMPASSION, would have required the Doctor to assess the condemned patient at least eleven hours before he was seen; and in fact tragicly too late.
I am not selling this as “thinking outside the box”. It is simple human compassion they and we’ll show in many other circumstances towards another human being. The offload delay numbers would remain the same. The math would remain the same. The available bed situation remains the same in real time dynamics. The Humane, the recognition of the very appropriate need for patients in severe pain to have A-HIGHER-PRIORITY- ACCESS- TO- DOCTOR- AND -CARE is the simple change: Simple corrective guidance. In the public interest, the absence of the CTAS F (reversed queue) is the measure of diminished morals, ethics, conscience and certainly the measure of unfulfilled professional mandates regardless of role and office within our hospitals.
So will this “rational fog” lift to reveal something manifestly anti compassionism and anti compassionist, to afford equality of QUALITY TEATMENT RESULT to all patients?
I am not impressed that Ambulance Services and Emergency Nursing care very much that a large segment of their mutual patient population suffers needlessly in severe pain. Where is their advocacy? The “we-have- no-influence” rolls of their tongues reflexively. Are they afraid to be labelled as “cowboys” or riders of bulls” in the hallways of our emergencies? I make this statement while thinking of my belief (not because its policy or law) that the patient on their stretcher IS THEIR RESPONSIBILITY= THEIR AMBULANCE SERVICE’S RESPONSIBILITY=UNTIL SHE IS TRANSFERED TO A HOSPITAL BED.
Nursing in our emergencies and the Ambulance Services are not part of the solution! I came across this quote on racism; inside the brackets are mine: “only a fool would place the moral responsibility for (compassionism) on anyone other than the (compassionists) themselves”.
Well, if I’m going to be dismissed as the “cowboy” in the hallways of their- emergency departments, it should be remembered that the truth in the hallways remains: that of a crime still not recognized; stigma still unidentified; and consequences for culpability not suffered.
Along with the doctors, Nursing and Ambulance Services are in a RUT. And their roles entail a bit more then the issues of "nurse-patient ratios" and of response times as the consequence of offload delay/wait times, which are after all are political issues. But to be a little satirical, a six minute response time versus an eleven minute response time SIMPLY MEANS that the many of our mutual patients who present in severe pain will arrive a whole five minutes sooner to begin their 5/6 hours of needless dehumanizing suffering in severe pain.
However the "rut" provides easy boundries within which these Health Care professionals feel much emotional comfort. You can pull a Bush-Blairian (or a BB) “I believe...We believe” that “the true genesis of the problem is offload delay...and nurse-patient ratios (no money, no staff, no beds and no space)”. But if it’s not a lie, it is exceedingly misleading; and certainly an insult to those patients who present in severe pain in our emergencies.
What offends my intelligence is the underpinning logic: the lack of compassion, the diminished morals and ethics and the erasure of the Hippocratic Oath are because of a poor economy/lack of money! THEY, THEREFORE, WOULD ARGUE THAT “A SOURING ECONOMY WOULD BE THE GENESIS OF THE RACISM IN OUR PROVINCE”, and our country; and alas our economy is never going to be strong enough. They are asking me to see the Mayors, as the fools, lobbying for more money from the Province, to create more jobs to deal with racism in their cities!? How absurdly reductive they are!
And wouldn’t you know it, the (Ontario) Minister of Health is coming with a bag of money; aren’t they lucky. Even if there is some superficial perception by many that such a reductive attitude has some success, it cannot be said that the factual reality of the lack of compassion in our emergencies is rendered moot. Offload delay is the light over the geography of compassionism, exaggerating the compassionists’shadows. They don’t see this because they refuse to see it; for what fear or agenda or what they’re protecting I have no idea.
May be I should infer from their behaviour that they do not perceive much gain in terms of self validation as professionals, to advance my advocacy to the appropriate level entities in the health continuum.
And the Minister of Health with the bag of new money is not going to demand changes to the current applications of the CTAS Guidelines; but will provide for one special “transfer of care nurse” per emergency department to work under the very same current application of the "Canadian Triage Acuity Scale" ofcourse. Clearly this is not enough. The new money to create offload delay rooms is a cry out loud argument in logic and ethics to expedite my call for higher priority access to doctor and treatment afforded to their patients who present in severe pain!!!The CTAS “F” LEVEL!! Because the CTAS2 non-pain-patient will have to wait less hours on offload delay; and therefore, less potential for an increase in acuity and deleterious effects. Why then must the severe-pain-patient remain behind the non-pain-patient or the typical patient immobilized on a back board ("just in case"), waiting in the queue to suffer needlessly?
As a Paramedic for twenty nine years my eyes are wide open, and during these twenty nine years I often fought not to allow my humanity to be rounded off or diminished; and not always was I allowed the dignity: The intent of my advocacy is not to decry offload delay as an issue to be resolved; but that there are compassionism and condemnation inflicted on a disadvantaged segment of "(our) mutual patient" population, in our emergencies. The patient in severe pain is betrayed by the designated medical authorities. And the Emergency Ambulance Services and Emergency Nursing are complicit in this betrayal. IN THE PUBLIC INTEREST: EMERGENCY HEALTH CARE TO THE CITIZENS OF ONTARIO, AND THE REST OF CANADA (AND THE WESTERN WORLD) REMAINS DISCOMPASSIONATE, DEFICIENT AND UNFULFILLED.
Nothing in these pages that I am sure some will dismiss as philippic, qualifies as new phenomena, and notwithstanding the “intellectual recognition” suppressed by “diminished morals and ethics”, I observe a certain emotional, psychological and nevertheless professional PRETENCE that “IT” does not exist.
PHILIP MICALLEF.
