Prolonged exposure to extreme human suffering can only have a toughening effect on an individual. Aid workers in famine-hit lands and war zones cannot afford to collapse in distress every time they see a child die of hunger or a family slaughtered by a stray missile. They develop protective emotional shells that allow them to prioritise need and urgency — so the badly injured or starved man with some chance of survival is preferred for treatment over the wailing infant who will inevitably die. To an observer their decisions may sometimes appear callous but they are essential for the welfare and quality of life of all involved.
Similarly, medical personnel have to develop emotional armour. Doctors and nurses must equip themselves with the defence mechanisms they need to stay upbeat and useful in harrowing circumstances. This is particularly true of those who work with sick children. Unwell adults have often brought their woes upon themselves through lifestyle choices, poor diets or careless driving, but children are invariably innocent and handling their pain must be extraordinarily draining.
Yet, as anybody who has ever had a child in hospital will know, the medical personnel who deal with them seem to wear their emotional flak jackets lightly and unobtrusively. As often as not the nurses will chat to your miserable toddler or cuddle your sedated baby as though they were the only children in their care. They hide their necessary detachment well.
Administrative staff keep their distance in a different way, as do health board executives, bean counters at the department of health and even ministers. They treat patients as numbers and often, it seems, as irritants to the smooth running of their systems. Their interventions range from the mundane and dispiriting — turn up for an appointment at a public clinic and you’ll find every other patient there is scheduled to be seen at the same time; to the inexcusable — witness the changes regarding the training of paediatric nurses that indirectly cost Roisin Ruddle her life.
Roisin underwent life-saving surgery within days of her birth in May 2001. She was born with a complex congenital heart defect that required a series of investigative procedures during the first months of her life. From the detail in last week’s report into her premature death almost two years ago, it seems that Roisin and her parents would have become very familiar indeed with the workings of our hospitals and health service in the 26 months of her life. It is almost certain that they met with much kindness and compassion during their involvement with the staff of Our Lady’s Hospital for Sick Children in Crumlin even if their final hours there have left Roisin’s parents feeling frustrated and confused.
They were instructed to keep Roisin fasting on the night of June 29, 2003 in preparation for surgery that was to take place the next day. They subsequently realised that staff at the hospital suspected Roisin’s operation would not go ahead as scheduled because of pressure from other emergencies. Yet all the pre-operative procedures — including putting the little girl on an intravenous drip — were completed.
After they were given the disappointing news that the operation had been cancelled and that they and the child faced the drive home to Limerick, the Ruddles maintain they had to ask for a small snack of yoghurt for Roisin because no food was offered. The family have also questioned the general level of care.
Did busy staff forget to properly attend to a little girl who had been fasting for hours? Possibly. Did the staff proceed with preparations for an operation they knew was unlikely to take place in the absence of a clear directive to abandon them? Probably. Was her clinical care that day nevertheless “appropriate”, as the report found? In the circumstances, nobody can say for sure.
However, when considering whether a decision taken in 1996 to change the way that specialist nurses were recruited — which made the work less attractive for candidates — impeded her general care and hastened her death, then the conclusion has to be that it almost certainly did.
Whatever oversights, insensitivities or short cuts the Ruddles encountered in the hospital, these were arguably the by-products of a medical service under extreme pressure. Medical personnel have to find ways to deal with the daily frustrations and setbacks brought about by the shortcomings of the system. After years of prepping tiny patients for operations that might not take place because somebody higher up has made a calculated pen stroke that depleted the essential support staff, it may be easier just to ignore the futility and unfairness of it all and simply follow orders.
The penpushers who made the decision to change the training of paediatric nurses have no such excuse. Up until 1996, school-leavers intent on a career in nursing could opt to train directly as paediatric specialists. But nine years ago, the system changed to require nurses to undergo four years of general training and then, if they still wanted to specialise in the paediatric intensive care area, a further three years of training.
The snag is that, during the first 18 months of that period, their salaries revert to basic level, with the Irish Nurses Organisation estimating that a nurse who wants to work in paediatrics must be prepared to sacrifice up to €6,000 in wages. When the training is finally completed, a paediatric intensive care nurse can expect to earn all of €2,500 extra a year compared with his or her peers — that amounts to roughly €1.25 an hour more for all the extra effort involved.
Given the obstacles that have been put in their way, those nurses who work in the emotionally challenging area of paediatric intensive care have to be singularly dedicated and caring people — they’re definitely not in it for the money. And when the financial recognition of their devotion is a positive insult, you can hardly blame potential intensive care nursing staff for thinking again.
Back in 1996 somebody, somewhere, made a decision that they must have known would have an impact on the numbers of nurses available to care for desperately ill children recovering from critical surgery. After that it was left to the directors of nursing at children’s hospitals to cope with the inevitable staff shortages as best they could.
Detachment from others’ anxieties may well be an inevitable feature of providing medical care. It is almost required by personnel on the front line. However, it is not acceptable in those who make the financial decisions. There can be no room in the health service for bureaucratic cynicism.
Last week a newspaper ran a photograph of Roisin Ruddle’s parents carrying her for the last time in her little white coffin. If there had been a few extra nurses on duty, for the princely sum of an additional €1.25 an hour, that child might well be still alive. All the financial imperatives and the management pressures in the health service should not make that realisation any easier for any conscience to deal with.
