Tag: racism

Categories
blacklivesmatter

Police Violence & the Opiate Crisis: Public Health Emergencies

In San Francisco today, the district attorney announced charges finally on a 2017 police shooting of an unarmed black man in 2017. This coming mere DAYS before the statute of limitations would run out, according to this article on SFist. Racial justice continues to remain foremost in the minds of lawmakers and politicians and thank god–this country cannot keep going killing people. Police violence is a public health problem. I’ve said it before and I’ll keep saying it. But even more so, that leads us to a more basic point: RACISM IS A PUBLIC HEALTH PROBLEM. When black and brown people DIE merely because they are not white, this is not a coincidence. This is racism, and quite frankly, it is a national emergency.

Also in the news today, another public health problem created by white people: the opiate crisis. Purdue Pharma has finally pleaded guilty to several charges related to its role in starting–and maintaining–the opiate crisis in America. Bottom line, the company admitted to 3 basic things:

  1. The first relates to LIES told to the Drug Enforcement Agency (DEA). Purdue lied about having a program in place to prevent pills from getting to the black market. In fact, they really profited from oxycontin’s widespread sale by people buying it on the street. The company also lied to the DEA regarding false information provided to the agency that helped boost manufacturing
  2. The company paid someone to provide doctors with patient info (Hello! HIPPA?!?!) that encouraged them to write opiate prescriptions.
  3. Lastly, Purdue Pharma paid doctors to prescribe oxy. Boom.

Of course, there was a fancy explanation for “how” and why all these things were accomplished but the bottom line is Purdue wanted to make money. It did. The Sackler family is still filthy rich, in fact, from drug money earned by the deaths of over 200,000 Americans. The cost to the healthcare system might never be able to be estimated, as the full ramifications have not yet been felt. The East Coast still suffers from a heroin problem but has been hit hard by synthetic fentanyl in the past few years. Here on the West Coast, we’ve typically been more of a methamphetamine place, but synthetic fentanyl deaths are rising now too.

The last full book I read on the subject was Dopesick by Beth Macy. It is an incredibly detailed look at how the crisis began, details of the ways in Purdue Pharma changed not only the marketing of pain medicine but the very way we practice medicine itself. I highly recommend this book if you’d like to know more about this subject.

One of the most disturbing parts of Dopesick was reading about how during Purdue Pharma’s massive “educational” marketing seminars, it promoted PAIN IS THE FIFTH VITAL SIGN as a new concept. This really reinforced the idea that new & stronger pain medications were necessary for the average patient–medications like oxycontin. Surprise! But this mantra regarding pain became adopted by accreditation organizations such as the Joint Commission and the American Medical Association (AMA) itself. In nursing school, it was drilled into my head. Treat the pain, because your patient can’t HEAL if they are in pain.

But all of this helped contribute to our opiate problem as all doctors, including those taking care of hospital patients, felt the need to write more and more prescriptions for painkillers. Patients themselves also tended to not be satisfied that their pain was relieved no matter how much narcotic they received. I mean, we were telling them that they should have NO PAIN.

In 2016, the AMA went so far as declaring that pain is NOT the fifth vital sign, and that new non-pharmacologic measures and cooperative pain management techniques should be taken to manage patients.

As a nurse in the ICU, I have seen an attempt to reduce the use of opiate pain medication. Some of this seems silly given the circumstances–such as a patient on extracorporeal membranous oxygenation (ECMO) only getting IV acetaminophen. I mean–they do have garden hoses jabbing into each groin, plus more usually… But for surgical patients, I am fully on board. You are supposed to be able to feel your incision the day after surgery. And when you cough, it is definitely gonna hurt. While you’re coughing. And then it will stop. Magic!

My personal opinion is that the best treatment for pain and prevention of other post-operative complications is walking. Don’t take a bunch of opiates, get constipated, end up with an ileus and too weak to stand. Get out of bed, sit in a chair, take a walk. Do that over and over throughout the day. Rest in between. You’ll get better faster than your neighbor who takes oxy and complains that it hurts and refuses to get out of bed.

If you have recommendations for other articles or books on the opiate crisis, please leave a comment as I’d love to read more on this topic! Or any topic…

Categories
blacklivesmatter

When police violence hits home

Within 20 miles of where I live, Vallejo, California suffers under the most violent police force in the state. According to this fantastic long form analysis by Shane Bauer in The New Yorker, “[s]ince 2010, members of the Vallejo Police Department have killed nineteen people—a higher rate than that of any of America’s hundred largest police forces except St. Louis’s.” In those 10 years, the city has paid almost $16 million in legal settlements, had their insurance raised significantly, and are currently still facing 24 use-of-force legal cases expected to cost upwards of $50 million dollars.

“It can’t be awful if it’s lawful.”

Joseph Iacono, Vallejo Police Lead Force Options Instructor

This is a small city where many black and brown families have moved, often being squeezed out of the historically minority-centered but now rapidly-gentrifying Oakland and Richmond. The police force is staffed mainly by white men who don’t live in Vallejo but get paid top wages, often leaving forces in places like Oakland to find a job where their violence is acceptable.

And you know my refrain… Who suffers when the white man is in power? Always the black & the brown & the women. Also the mentally ill, the senior citizens, the homeless, and any other disenfranchised and powerless groups. Vallejo has gone bankrupt trying to pay the police officer’s increasing wages and benefits, often eliminating funding for roads and senior centers entirely in the process.

This is a city with a public health problem, and that problem is POLICE VIOLENCE. Defunding the police–perhaps even disbanding and restarting from the beginning seems to be the only situation in Vallejo.

All I can ask from you is that you know what’s happening in your area. Are people suffering like this? Can you help? Stand with your fellow citizens!

Categories
blacklivesmatter

Really, just now an east coast hospital proves that black people are discriminated against during the kidney transplant process?

I could just about die this very serious news article was so funny to me. I say with all sarcasm intended, if you can’t hear my tone. The general theory of article is there is a lab test that measures kidney failure correctly in white people (surprise) and is inaccurate for black people. It’s been causing black people to be overlooked for kidney transplants for years! So once the scientists did a little recalculating, we have a formula for both sets of people that reflects their kidney failure more accurately!

Wired: “How an Algorithm Blocked Kidney Transplants to Black Patients”

You wouldn’t think this would be so hard to figure out, except medicine has been a white man’s game since its inception. Most research on procedures and drugs, even today, is still done primarily on–you guessed it! Men!!! Of the white variety. But other things struck me funny (?) about the article as well. Let me run down my giggle list:

  1. Wired Magazine a quite prestigious news organization for science and technology (and I must admit, must I?, a former employer of mine) is covering this topic. This topic is not new or groundbreaking or pushing forward the field of medicine in any way. I find this interesting.
  2. I literally had no idea that other hospitals (geographic areas? States etc?) did not use the recalculated eGFR to determine the severity of black people’s kidney failure. We’ve been doing this at my facility for at least 10 years… I remember when it changed, but time flies when you’re wiping ass. Our chemistry reports show both values automatically, actually.
  3. Last but not least, I want to mention that getting selected and then listed for an organ transplant is a crazy process, one mainly shrouded in mystery to the average American. But it is not a joke. There are not nearly enough organs for people that need them. Surgeons that do these procedures are in competition to get the organs for their patients, to perform the surgeries at their hospitals. They often have quotas they have to hit to stay certified as a transplant center (both for the doctors and the nurses), and for some organs like livers and hearts and lungs, the patients may be in the hospital for months waiting… not even at home. Also, as this article notes, the process can be burdened by institutional racism. Sometimes it even looks a lot like real racism– for instance the young black men in our advanced heart failure service do not usually succeed in getting a heart transplant. They certainly qualify and are listed. But we had one (and he is a sort of amalgam if patients that serves as an example), we’ll call him Kevin. Kevin was so tall, like 6’4″ and he was like a brick house, weighed maybe almost 300 when he came in the hospital and last 50-60 pounds in the 3 months he stayed in. We waited and waited but we couldn’t find him a heart. There were (per the doctor) about 3 other guys if his size on the transplant list ahead of him. I used to joke that we would need a bus of NFL players to get into an accident for these guys. Typing that now, I realize that is some really dark stuff, but Kevin and I needed a laugh of any kind in those long days where he couldn’t sleep and was stuck in his 12 by 20 hospital room for weeks on end. In the end, he got an LVAD (left ventricular assist device) because it had enough power to help his heart–and it meant he could finally go home and live some life.

Some day I’ll write more about transplants, even though I worry that I’ll be breaking some secret code to just keep quiet.

Categories
Quick Notes

I failed to act in the moment

On my middle night shift this week, a grueling 14 hours with multiple assignments and emergencies and ending in a tad bit of humiliation but NO EXCUSE, I witnessed something as I pulled out of the hospital parking garage that at first I didn’t even really process. But seconds later, as I turned right, the image absolutely set my mind and heart racing.

The exit of the hospital garage is oddly narrow, and this particular morning, there were a few cars coming and going. Approaching the exit, I noticed some security guards huddled together a few feet away from the temperature screening checkpoint. As I turned right at the corner, I kept thinking: Why were there four security guards squatting like that? Were they on top of a person? Was there a code blue happening because there were no doctors or nurses there… do they need help and should I turn around and go back??? Rapid fire thoughts were rushing through my mind. At this point, I was 2 blocks from the hospital. I could still turn around. But if it was a code, wouldn’t the day team have arrived by now and wouldn’t they all be more useful than an exhausted off-shift night nurse???

But then another image came to mind. These were security guards. Four of them. Huddled around and possibly on top of a person laying on the ground. WERE THEY RESTRAINING SOMEONE???? ON THE GROUND? Were four large security guards holding down a person, probably a black man, near our hospital entrance, and was it possible this man could die this way?

In my head was just a stream of panic. Surely something like this could never happen at MY hospital in MY town… by now I was six blocks away. Freaking out and lucky I hadn’t caused a distracted accident, I pulled over and had an idea. I called a colleague on the day shift, the nurse who was acting as our Rapid Response Nurse (RRT) that day and who I had trained personally a few years earlier. I knew she was ballsy enough to get a guy out from under security and skilled enough to save his life is she had to.

She understood immediately and told me she’d get back to me.

I took a few centering deep breaths, knowing I’d taken the fastest action I could based on where I was. But vowing that I would not keep driving next time my brain even hinted to me that something wasn’t right. I need to stop immediately in these situations. I owe it to my fellow humans, to people of color especially who find themselves unfairly targeted in a society plagued by both overt and institutional racism that extends through through every level— from basic human rights and healthcare to policing to employment policies to the way the government as a whole is run.

And I especially owe it to those I work with, if these events are happening where I’m employed. Healthcare needs to be better. We need to set an example for how people should be treated. And personally speaking for our security guards, I want them to feel enabled to find new ways of dealing with people that is less dangerous. Security guards (or officers as they’re called at my hospital) exist in that space also occupied by police where the culture can lean toward a violent military style. But is this necessary? Is this right??? Should this be the first line tactic if most of the people dealt with are 1) agitated & aggressive patients, 2) homeless people living around or seeking inappropriate care at the hospital or 3) family members on drugs or alcohol who abuse medical staff? I think not.

I arrived home that morning to find a text from the nurse that I’d called for help. She told me that when she’d gotten there, the guy wasn’t on the ground anymore. He was sitting in the back of a cop car. “Being arrested, don’t know what for…” her brief note read. I felt a small bit of relief that he’d survived his encounter with being restrained on the ground. But now I also felt another twinge of sadness. I wondered if he was just a homeless person who had been bugging the temperature screeners. Maybe a schizophrenic off his meds? Maybe never on them. I wondered if being arrested was really necessary. I texted this in response. But the message I got in return made me sad: maybe there was a restraining order against him. Maybe, but in this case I’ll never know. Maybe I’m too soft, but I think there are other ways to wait for the police to arrive than with a person restrained on the ground.

Categories
heathcare politics

Institutional and other racism in healthcare I’ve called out this week

Heath care is a strange place where I see silence occur in many forms as a type of violence against black & brown peoples, and especially important to me: women… this week, 2 things. In my career I’ve never been the silent type, but I hope sharing examples of what I classify as racism and sexism in healthcare can help expand our conversation. And if even one more person gets a voice… that is all that matters.

1. We received a patient from the emergency department. I was reviewing the EKGs since she had a funky rhythm on telemetry… and up in the corner, where you can type in demographic info—but you are not required to—I see that this patient is labeled as “Oriental.” I check the other EKG. It says “Asian.” I am floored. Why would you type this in? “Oriental” describes a rug not a person. I speak to a colleague who used to work in the ED and we contact a charge nurse there to follow up on this. Giving this person the benefit of the doubt and not reporting to risk management for now.

2. The second case is more complicated, but one I see in different variations much more often. Details are approximated from several cases. An older Asian woman, a mother of loving involved children and a wife, has been hospitalized in the ICU since April. She has “failed extubation” many times and had a breathing tube for the majority of her time with us. She has also had several cardiac arrests. She has end-stage renal disease and thus has been on continuous dialysis as well.

This is a critically ill patient who due to her multiple conditions and has one nurse assigned only to her— to run her dialysis and keep her safe. Every night at rounds someone offhandedly mentions that we should really address goals of care with the family.

Discussing goals of care (GOC) is one of the main things doctors are responsible for in the ICU. You need to assess how the patient would like to live should she survive to be discharged from the hospital. And this sounds brutal, but upon admission or during the course of an ICU stay, many suffer drastically life-altering medical events. Strokes that will leave you paralyzed on one side and fed through a tube in your stomach. A heart attack that will make you unable to do any activity but walk from your recliner to the bathroom. A kidney injury that will require you to go to dialysis three times a week for the rest of your life. A lung infection that damages your lungs so badly that you need a tracheostomy and rely on a machine to breathe for the rest of your life—thus making it nearly impossible to ever go “home” again.

So it is up to doctors, and sometimes nurses too, to have conversations with patients and their families about these things. Is this how your mom would want to live? What does she enjoy doing and will she be able to do that after her hospitalization??? The answers to these questions can inform then what treatments we provide—but more importantly, don’t provide.

So back to our older Asian mother and wife, receiving dialysis and unable to come off the breathing machine. At this point, she’s been in the hospital 1.5 months. It seems like some GOC discussions should have taken place, right??? Well this week, she received a tracheotomy. During the procedure she received sedation, which they continued for 24 hours post procedure to allow for more comfort during the initial period when she might bleed—so that she could rest, hopefully reducing the risk of said bleeding.

During the second night in which she didn’t wake up, despite being off sedation and on dialysis—which would clear the drugs, I started getting alarmed. What would happen if she never woke up? I went into the chart to review the GOC notes I so naively assumed must be there. You see, I wasn’t her bedside nurse—but instead one of the charge nurses on a busy ICU in a major city.

I could find no GOC notes. No palliative care consult. In a month and a half. Nothing. What the f*ck was going on???

An overly solicitous deference to the family of Asian women for decision making and tacit agreement to “do everything” without a conversation. In these instances, the female patient is most often left out of the discussion altogether. Even if the patient is clearly suffering or clearly doesn’t want the interventions. The nurses often become the patients only voice— forcing the doctors to talk to the family about the patient’s wishes.

This is a practice done out of respect for “traditional” values in Asian cultures, but is ultimately looks to me like racism and patriarchy when it flaunts modern medical ethics and the premise of “first do no harm.”

This patient had no desire for a tracheostomy. In fact, she hated the breathing tube. She hated the hospital. Will she retain her will to live when she is put into a long term care facility? My feeling is no. And so it was my duty to speak up. To ask why there had been no palliative care meeting. To question the ethics of what we’d done already. When I go back to work next week, I hope to find some answers in her chart.