Authors: Julie Salamon
Hospital (34 page)
“Bernie said Steve didn’t call, and Steve said Bernie didn’t return my call,” said McDougle. “They don’t like each other, so they don’t communicate and they blame each other. Who’s right? I don’t know who’s right. There are times you have to draw the line, and this didn’t seem to be one of those times. So now we’re back to square one with trying to hire a nurse director.”
McDougle looked at me poker-faced. “But square one is better than negative three.”
I sent Davey Gregorius a note asking him what he thought about Hatzolah.
His reply:
I mostly have had good experiences with Hatzolah. it is unfortunate that they sort of get a “bad rap” from the other EMS/Ambulance crews. i think they got bad reputation 1. some people infer that they only run Jewish patients (which i do not think is true . . . . but certainly 95% of the people they bring in are Jewish). so i think it’s a sort of counter-discrimination. 2. (i am told) they respond faster than any city-wide (private or government) EMS “company”. not sure of the exact times, but i was told something to the effect of average response time for Hatzolah was like 3-4min vs. 8-9 minutes when calling 911 . . . . so if this is true, i can see why FDNY and Maimonides EMS workers would be “jealous”
you’d have to ask some people a little more close to the program than i
one thing i do recall is that they usually gave a very professional presentation of the patient they brought into the Resus [Resuscitation] room
and 3. the other thing was they were notorious for “Hatzolah-fications”, which is a unnecessary “notification” called in by Hatzolah. a notification is when the ambulance crew (regardless of company) calls ahead to the ER to warn of a life-threatening condition (stroke, heart attack, bleed, etc), and thus all Notifications were immediately triaged to the Resus room, instead of waiting in that line at triage and then waiting however long to be seen. the general consensus is that Hatzolah calls in some Notifications that did not need to be notifications. that the Hatzolah members would call in a Notification for an elderly Jewish patient that they just wanted to get seen faster instead of waiting 1-2 hours, although they really were not sick enough to require “jumping the line”, if you will . . . . i think overall, Hatzolah is great and if i was injured or having a heart attack, i’d call Hatzolah. also i wouldn’t want to piss anyone off. Ha
January 8, 2006
Daily Log—J.S.
Daily Log—J.S.
A couple of months ago, Steve Davidson told me about Ann Marie Ceriale, a youngish nurse he’d hired to be a nurse manager in the ER. The nurse manager’s main job is handling discharges, organizing the floor nurses to make sure each patient has been seen, diagnosed, and then sent home or to a hospital bed. Nice and orderly job description in the abstract. Davidson hadn’t been able to find anyone willing to take the position for the past two years. Before that the department
regularly ran through nurse managers at a rate of one a year or so. Ann Marie sounded like someone I should hang around with, to see if she survives.
regularly ran through nurse managers at a rate of one a year or so. Ann Marie sounded like someone I should hang around with, to see if she survives.
Davidson agreed but asked me to wait until January. “Yeah, January sounds good,” he said, looking worried. “Barbara Sommer, who’s been in the ER twenty years plus, is becoming associate VP of nursing as of January 2, and I won’t have a nursing director, just this new nurse manager. She’s a nifty young woman. She’s been a charge nurse on the cardiac-cath recovery unit and worked a couple of ER’s in Westchester. She’s got some great leadership chops—she wouldn’t let me intimidate her. I like her. She pushed back.”
The other day I reminded him about introducing me to Ceriale, and he said he would see how she felt about having me tag along with her. “I don’t want her to feel too much on the spot,” he said. “She might . . . I don’t know how I feel about it. Her success is pretty important to me, I don’t want her to pull her punches.” Then he shrugged. “She’s a grown-up, you should talk to her.”
I called Ann Marie. “Sure,” she said, “you can follow me around. Just don’t go into shock.”
On January 9, Ann Marie Ceriale came to fetch me at 9:00 A.M. in the pleasant-enough waiting room at the walk-in entrance to the emergency department. She was thirty-four, had long brown hair and big dark eyes, pretty, Italian-American, a little chubby, assertive. She told me she lived in Yonkers, four blocks from her parents, and that she’s lost more weight in the six weeks of this job than on any diet, including the twenty pounds she’d dropped on Jenny Craig. In the hallway leading to her office, I read the advisory posters on the wall and felt a mild panic at the implications in these instructions on what to do in case of stroke, chemical terrorism, smallpox.
On the way we passed through the emergency room, which appeared calm, with patients neatly deposited behind curtains and doctors and nurses walking rather than careening. I noticed a woman doctor with the unlikely but momentarily appropriate name of Placid Bone.
“Just wait,” said Ceriale. “Two o’clock. You can set your watch.”
“What?” I said.
“Chaos,” she said. “You can set your watch by it.”
Ceriale stopped to snap at a nurse who was reading the newspaper. “There’s no time for this,” she muttered.
For six weeks she’d been trying to connect Dr. Davidson’s continuous quality improvement model to reality. But almost every day of the six weeks she’d been in the ER, Ceriale had been short of nurses. She usually spent the first couple of hours at work trying to find subs. She had six open positions, all on nights, and depended on the staff she had to do overtime. One of her jobs was to solve the staffing problem. She was thinking of using more travelers, who worked on contract. She had been a traveler and loved it. She’d seen California that way, Sonoma County. If you don’t show up, you don’t get paid, while the Maimonides nurses were unionized. “Call in sick and you get paid,” she said, adding quickly, “I one hundred percent support the union.”
When she first walked in from the street to the ER, her impression was that it was a “complete disaster.” She said, “I thought, ‘I would never want to be a patient here nor would I want to work as a nurse,’ and now I’m a nurse manager.”
But she came to see there was both method and madness. “There’s actually a very organized and systematic way we’re doing business here, but from the outside it looks like a complete disaster,” she said. By then we were in her small office, decorated only with a photograph of a sunset taken by Ceriale at Club Med in Mexico.
“We’ll get a massive amount of discharges today, because it’s Monday and a lot of beds open up on the floors, because doctors don’t do a normal amount of discharges on Saturdays and Sundays,” she said. “Meanwhile, the ER is backing up throughout the day, so by the time we get the beds available, we have a flow list of fifty or sixty and one or two transporters.”
She said it was ironic that she took this job, because what she loved about nursing was the clean slate at the end of the day. No matter how grim or hard or tense, her duties were finite. “At the end of the day, it was the end of the day,” she said. “At the end of the day, you handed off patient care to someone else. Now there’s no end of the day.”
The ceaseless demands, the unending pile of loose ends, reminded her of the seven years she spent working at an insurance company. “I had files of injury cases I had started at the beginning, and when I left seven years later, I had the same files,” she said. “Instead of taking up one single file folder, they were taking up a drawer in litigation. They had a life of their own. There was never a time I could say my desk was completely cleared off. This is very similar. My desk is never going to be clean. The end of my day is never going to be a fresh start or the end of the day. Your days off are not your days off.”
At 11:00 A.M. we went to a management meeting led by Carl Ramsay, the medical director, Dr. Ponytail. The head of the ambulance service said the fire department’s new computer terminals with GPS tracking weren’t working and screwed up the entire system over the weekend. Lab problems, staffing problems, a stab wound in pediatrics. Ramsay told the group that the new nurse director hadn’t worked out, though he didn’t mention the Hatzolah veto. “We’ll do fine so long as we are talking to each other, respecting each other,” he said wearily.
Next time Ceriale and I walked through the ER, the earlier calm had evaporated. I checked the clock. As Ceriale had predicted: It was 2:00 P.M. Chaos time.
We walked by an Orthodox man on a gurney surrounded by women praying. A blond young man on a stretcher in the hall complained he’d been waiting too long. Dr. Huang and one of the cancer fellows swooped in to press the belly of an African-American woman. I saw Dave Gregorius bee-lining it for the “resus,” or resuscitation room, reserved for possibly about-to-die patients needing swift attention.
Back in Ceriale’s office, she showed me the tracking board on her computer. She was starting to get the hang of it, using this snapshot to find hang-ups in the system. She could see that at 2:28 P.M. there were seventy-three patients in the ER, none of them in pediatrics. A sixty-seven-year-old female with complaint of chest pain had spent eleven minutes with a nurse and was now with an attending physician. A report was given to the doctor on the floor, patient admitted to telemetry. Team One. They’d requested a telemetry bed. Here on the cardiac monitor, her EKG. Lab orders. Blood work, vital signs, history.
But between “patient admitted” and “they’d requested” lay the gap between “continuous” and “quality improvement.” Minutes could quickly become hours. “It’s a very busy emergency room,” said Ceriale.
Her beeper went off. She stared at it. “The beeper, the beeper, the beeper,” she moaned. “I already had my first dream of the beeper going off. I got up Saturday at five in the morning searching for the beeper, which was right next to my bed.”
When she found it, she realized that the beeping had infiltrated her inner consciousness. It was only a dream. The beeper hadn’t gone off.
For a moment Ceriale’s entire being seemed to sag with weariness. “I started at the busiest time of year without a mentor and came into a situation that was a big mess,” she said. “I’ve been here for six weeks, and three days out of five I’ve gone home crying. It’s not something you can show either. You don’t want them to see you sweat, like they say on the deodorant commercial. Every other day I’d like to quit, but then on the in-between days I think it was a good move and I’m happy to be here.”
She straightened herself. “Now the holidays are over, staffing is starting to get a little bit better, my job will start to get a little bit better,” she said. “I have a lot of confidence in myself. I think I can do the job. Not even think— I know it.”
On that hopeful note, we said good-bye and agreed to meet later in the week.
Four days later—Friday the thirteenth—when I stopped by the ER, someone told me that Ceriale was gone. No one knew where she was or if she was coming back.
Nine
The Code of Mutual Respect
MAIMONIDES MEDICAL CENTER
Department of Perioperative Services
You are invited to the first
Crucial Conversations
training session
Topic: “Getting Unstuck”
Learn: How to recognize what Crucial Conversations are, and the
consequences of not having them!
Crucial Conversations
training session
Topic: “Getting Unstuck”
Learn: How to recognize what Crucial Conversations are, and the
consequences of not having them!
DATE: Friday, January 13, 2006
TIME: 7:00 A.M.-8:00 A.M.
PLACE: Schreiber Auditorium (Admin Bldg., 2nd floor)
TIME: 7:00 A.M.-8:00 A.M.
PLACE: Schreiber Auditorium (Admin Bldg., 2nd floor)
It had been a long time since Alan Astrow had thought about the former colleague at St. Vincent’s he once referred to sarcastically as “Mr. Doctor” (as in, “He thinks he’s so great he calls himself Mr. Doctor”). Three years earlier Astrow was covering the oncology service when one of Mr. Doctor’s patients was about to go into surgery, to have his spleen removed for a cancer biopsy. The patient was elderly. Before the surgery, pathology reported to Astrow that the lab already had tissue that showed metastasis of cancer, making the biopsy unnecessary. Unable to reach the patient’s doctor, Astrow spoke to the surgeon, and they decided to call the surgery off. When the family asked why the procedure had been canceled, Astrow told them. The cancer had spread.
The next day, just before his daughter’s fifth-birthday party, Astrow received a call from Mr. Doctor.
“You asshole,” the conversation began.
You asshole!
Mr. Doctor continued, “You shouldn’t have talked to the family.”
Astrow couldn’t believe it. They might have killed this patient in the OR. Okay, maybe the surgery wouldn’t have killed the patient, but it wouldn’t do any good. Why should an old person with serious hematological malignancy run the risk of major surgery for no good reason?
And his thanks for preventing what could have been a disaster?
You asshole!
So he gave it right back to Mr. Doctor.
He spoke softly as usual, but his words were riposte, not reply.
“You almost killed this patient,” he said. Even as he spoke, Astrow knew he had gone too far. Mr. Doctor’s recommendation for surgery hadn’t been unreasonable with the information he had. He was angry with Astrow not because he’d called off the procedure but because he had delivered the upsetting diagnosis to the patient’s family instead of waiting for Mr. Doctor to return.
Astrow’s empathetic self knew that Mr. Doctor was concerned for the patient’s family and for his own reputation, and that hundreds of cuts and slights and deliveries of painful diagnoses had turned him into the brittle, rigid, wounded individual that he was. Astrow knew he should apologize, because someone had to bend.
But sometimes he got tired of bending.
The bitterness ruined his daughter’s birthday party for Astrow. For weeks he agonized about the nasty exchange, alternating between anger at Mr. Doctor and frustration at his own inability to ask forgiveness even if he did think the other man was a self-righteous jerk.
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