Culture in the workplace

In know that others have written about this before, but there is a phenomenon in the emergency room where every patient triaged has a respiratory rate of 20 per minute. Now I understand that for most realtively healthy adults, presenting for lacerations, bumps scrapes…having an exact respiratory rate, or any respiratory rate is probably extraneous information. But kids are different. As much as I’d like to say they are just little adults, they are different. (OK, I really do believe they are just little adults, but Flea would get really upset with me…)

In teh past 3 days I’ve sent three sick kids to our regional children’s hospital, all with respiratory complaints. The first was the first born child of a teenage mother, 2 months old. The baby looked fine in the ER and was breastfeeding easily. Mom’s chief complaint…”He wasn’t breathing”. In this case, an accurately documented respiratory rate seems important, doesn’t it? How about an oxygen saturation? Why wouldn’t the triage nurse measure and record those things? Why does it require me to assess the patient first, and THEN ask the nurse to check and document his vital signs? It wasn’t like I was asking for a remeasurement of them…

The second patient was only 2 weeks old, again with respiratory complaints. In his case, vitals were documented, but weight was not. Hmm…being off by a kilogram in a 2 week old child can be pretty bad. When I asked the nurse to weigh him before giving a mg/kg dose of medicine, the nurse gave me his birht weight, then said that he looks like he’s about 3 kilos. I asked him politely to weigh the baby on the scale.

Today’s was a four year old child with asthma. The PA told me that she was pretty sick and we came up with a preliminary plan. I looked at teh vitals…respirations 20, oxygen saturation 94%. I walked into the room to see a panting child laying on the gurny…clearly breathing much faster than 20. I have to admit that I didn’t count her respirations (my watch is broken), but I asked the nurse after the respiratory treatments, steroids and antibiotics to remeasure the respiratory rate. “mmm about 26.” I didn’t think much of the phrase “about”, I just figured she was doing some math in her head and rounded up or down. I looked back in on the child and she looked better, but still clearly sick enough for transport. When teh transport team came and checked their own vitals, her respiratory rate was finally properly measured at 60. Hmm. About 26 was a little off.

I am not complaining about the specific nurses involved. They are all good and caring nurses. This is more about the nursing culture. While our hospital achieves high rankings for nursing care in our inpatient units, the way the nursing staff is treated in the ER is abysmal. Is it really my job to ask for basic documentation? To have to ask the initial triage nurse not just record, but actually count and measure the respiratory rate on a child in respiratory distress? To weigh a 2 week old infant who is ill?

These small omissions add up to big, big problems. They reflect a culture in which the nurses are neither asked, nor expected to think for themselves; a culture in which the nurses are disrespected by their supervisors, overworked and at their wits end to find spaces for all the patients and time to treat them all.

What’s the solution to problems like this? I simply don’t understand the disparity between the inpatient treatment of the nurses and the treatment of the nurses in the ER. Help.

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