As it turned out, only one other person had arrived overnight. He was a thirty-four year old man who presented with and endorsed extreme anxiety, which responded pretty well to a bit of medicine. Now he was settled and ready to go home. Often the duty doctor will just cut these folks loose without involving crisis workers so I was curious what else was going on for this fella. The answer was in the notes. This was his third visit. The presentation was similar each time, always at night and always late in the week. I wasn’t sure what that meant but I figured I knew who could give me an answer, the anxious man.
A half hour later I was ready to look for the duty doctor, Juli Ward, to fill her in on Dave Maxwell, the anxious man. I found her washing her hands in the anteroom behind the care desk. “Do you have five minutes to talk about Mr. Maxwell, the anxious guy that was held over last night for me to see?”
“I sure do? Why didn’t they send him home last night?” Recognition flickered over her face. “Hattie thanks for this morning. Thanks for taking the lead and getting someone down from the unit. And thanks for working with the police. It all went quite smoothly. That Jack guy was great! Thanks again.”
“Hey, no problem. I was glad it didn’t get out of hand. I thought we worked pretty well together. And yes, Jack always does a great job. If you get a chance, when they do their review of the incident, can you mention him? It helps us justify pulling from the unit to help out.”
“Of course. I forgot about the incident review. The incident part seemed to evaporate once we got into it. I better get my notes dictated. I will make sure to recognize Jack’s great work.”
“Well, if you can mention your observation that it seemed to evaporate once he got into it would be appreciated. They are looking at near-misses and that one comes close to the definition. Anyway, back to the business at hand” I smiled as I ploughed on… “our friend Dave Maxwell would generally have been sent home last night but I think that when Dr. Leroux, the duty doc on last evening, pulled up his records he saw that this was visit number three with same presentation. Coincidentally, the other visits were also on a Thursday. So, I asked Dave Maxwell a few questions around that.” Juli Ward nodded for me to continue. “He’s visiting from North Bay to consult on a production improvement on the line at the car plant. The work is stressful because his assessment of their current state-of-affairs revealed a need for more substantial change and both brass and line-workers are peeved. He’s been sorta fighting his way through the whole consultation. On top of that, on the weekends he goes home but he and his wife have been having some issues and he doesn’t look forward to more arguing.” Juli Ward made the hmmm sound.
“On his last visit, which was the first repeat, once the loraz had done its job the duty doc gave him some literature and robust encouragement to look up someone to help him work his way through this. He didn’t do that because he didn’t know how long he would be here in Carter. His schedule is up on the air. Because he’s not back in North Bay during the week, it’s hard to set something up. He’s basically overwhelmed off the map. He seems to be able to hold the demons back for a while and then they storm his beaches. If you are good with this, I am happy to put him on our list for post-emerge crisis service and see if we can bridge the gap for him. He just learned he has up to three more weeks in town, so if you add a little bit of anti-anxiety…just a little bit…” I emphasized by putting my thumb and forefinger up to my nose, about a quarter inch apart “then we can likely avoid three more late night visits.”
“That sounds reasonable.” Juli concluded. “I will need to eyeball him myself. Do you have a moment now?” I knew the duty physician would need to have a look herself, especially since I was asking her to renew a prescription of anti-anxiety medication. In fact I might have been concerned had she not wanted to confirm it all with her own ears. For many years the risks associated with ‘pams’ like diazepam, or Valium and Lorazepam, or Ativan were underestimated. These meds are pretty addictive and are now taken very seriously. We are getting to the same place with narcotic meds like oxycodone, in its various forms but in the interim many, many lives have been unalterably damaged. I appreciated this in a very, very personal way.
Juli Ward and I reconnoitered with Dave. He gave a thumbnail of his story to her, confirming what he told me. Dr. Ward explained the medication she was prescribing, explained why she was ordering such a limited number of tabs and advised that she would notify his family physician back in North Bay because she expected him to follow up on this before it became more problematic. I checked the calendar and entered him in a slot with Viv on Monday evening, after he finished work. Juli thanked me and headed off to her next destination. I checked my watch and realized I was running late. So much excitement for one short morning, and I was meeting up with Bridie later this afternoon!
It was 1145 by the time my butt hit my chair in our shared office. Jenn had stacked my mail on top of the keyboard so I wouldn’t miss it. Conference fliers, internal announcements, phone records and ….ah ha there was the reason she’d left everything so prominently: an overdue file report. There went my lunch hour. But first I wanted to track down Rudy to give him the heads up about the incident this morning.
“Jenn!” I announced as I rounded the corridor “Thank you for delivering…the mail” I said holding up the delinquent notice with a smile and a wink.
“You better get at it girl! That’s a second notice.”
“I’m all over it.” I nodded with fake solemnity. “Where’s Rudy? Anywhere nearby?”
“I think he’s expecting you. With this on-line incident reporter, he knows about trouble before its even over. Not to worry though, I believe his exact words were: when Hattie thinks its time to come and fill me in, I’m pretty sure she will. Send her my way.”
Rudy is a cool customer, so I wasn’t worried about being chastised. I rapped on his half open door and peered around it into his office. The space wasn’t large to start with but Rudy wasn’t a good putter-awayer, so the room shrank in proportion to the piles of reports and magazines. He was on the phone but motioned me in. I moved a stack of notices, likely including my delinquent workload report, and sat in the chair across from him. It sounded like his call related to setting up a meeting; in short order the task was complete and Rudy provided me his full attention.
“Sounds like you had an interesting morning” was his greeting. “You OK?”
I noticed he wasn’t smiling but I couldn’t judge the origin of his concern. “I’m good.” I stated with certainty. I was just on my way to see you. There was one other guy in emerg I had to finish first.” I guess its just human nature to be a little defensive when one’s performance feels like its being called into question, although I wasn’t sure so far if it really was or if I was reading more into this.
“Oh right. Thanks.” He nodded. “You don’t have your notes in the system yet, so I just need to get the facts from you verbally…”
I cut him off “Rudy, I just got into the office. I will get the notes done right after this. Actually, it was my plan to do them while I ate my lunch because my afternoon is jammed.” It wasn’t ordinarily Rudy’s nature to wind himself up about timelines. “Have I missed a deadline?”
My growing annoyance was now discernable. “No, no, no. Sorry Hattie. I’m not troubled with you…” I shrugged, lifting my open hands and cocked my head to the right in the universal ‘what’s up’ signal.
“Linda Berwick, the Team Leader in emerg entered the event into the system as a category four and that means an alert was forwarded to each and every member of the senior team. Now, I need to know what really happened before Beth-Anne crawls up my ass!” Beth-Anne, our Director was Rudy’s boss and in my experience she was a serious manager; she took it all by the book.
“A category four! Why in heaven’s name!”
Rudy turned to his computer screen and clicked open a box he had obviously minimized while he was sorting out his schedule, during the previous phone call. “Code White, police involved, property damage, chemical restraint, significant risk of personal harm to patients and staff…” he read from the glowing template.
“In theory, those criteria were all present.” I muttered through pursed lips. “However, does she in any way indicate that Jack, Jack Solomon from the unit, and I had it under control? The man settled right down, took the so-called chemical restrain orally and without argument, then departed willingly with the cops.”
Rudy paused to re-read the text in the report. “More or less…she focuses on the damaged bedside table and the fear expressed by a couple of the other patients in the department, and by a couple of the nurses. I should probably tell you, even though she didn’t put this in the report, she spoke with her boss about you taking over and managing the event. She said you even called off the police.”
I let that hang in the air while my blood pressure rose, probably to near-stroke level. I noticed that I was sitting forward in the chair, as if ready to pounce so I tried to calm myself with a deep breath before I answered. And I sat back. “Rudy, this perception will need to be corrected.” I blew the next deep breath out into my lap. “In my opinion, and apparently in the opinion of Dr. Ward, the police and Jack Solomon, this situation was handled well, and safely. Obviously, my notes will reflect that. My notes, which I will be entering as soon as we are finished here.” I checked my watch to see it was now 1205 and my next appointment was with Bridie at 1330, or 1:30 PM. “I’m assuming, unless you have any other questions or accusations, I am free to go back to work?”
“Hattie, calm down.” Did I detect a note of gentleness? “Of course, I am not accusing you of anything. I’m sorry it sounded that way.”
I cut him off again “I don’t think you are accusing me of anything but clearly someone is – and as far as I can see that someone is Linda Berwick.” I paused only a second to steady my voice, which can tend toward shrill when I get my back up. “This needs to get fixed.” I added slowly and calmly. “There was a risk this morning and we resolved it. We resolved it so that no one was hurt. We resolved it so that the patient received the care he needed. His safety and dignity was not jeopardized. I didn’t even realize the damn bedside table was damaged. Listen, I responded to a Code White, I did take control but that’s because I knew immediately what to do…I wasn’t hiding behind the care desk! Jack Solomon did a phenomenal job settling the guy down and the cops, the cops did what they are supposed to do – only the amount of involvement that was required. I didn’t call them off; I asked them to standby until we completed our assessment.”
“OK”. Rudy replied. “Get your notes in. I will document our conversation and meet with Beth-Anne. Based on what you describe, this was not a category four. But at this point only Beth-Anne can change that. As for Linda, let me think about how to handle her”.
“I can handle Linda. I will handle Linda…”
This time Rudy cut me off “don’t handle anything but your notes for just now; savvy?”
“Savvy.” I resigned. “I’ll touch base with you before I leave for the day. Right now, I have more to do than I have time for.”
I departed without further comment and marched back to my cubby-hole. It was now 1220. I spent the next forty-five minutes constructing my notes bout the incident in emerg this morning then entering them in the system. I deliberately did not check Linda’s entry before hand. Let someone else iron out the discrepancies. Then I added the link to the incident report. Only after all this did I check the original entry. As I said to Rudy, in theory everything Linda had documented was fact but somehow her facts insinuated more danger than I believed was present. I noticed that Jack’s notes were linked already. Juli Ward’s notes were not on file yet but given I had just left her I suspected they may not arrive until later. My guess is that physicians had a bit more leeway and I figured her note would be linked later by someone from medical services. Sadly, I didn’t have the file authority to read Jack’s account unless I logged back into the patient file and I was reluctant to leave those tracks. I checked my watch again. It was now 1315 and Bridie was coming in for the first time since her radiation. I still had to gobble down my sandwich and brush my teeth. While I ate, I sent a quick email to Rudy indicating the paperwork was finished. Instantly, I received a ‘thanks’ in reply.