Thursday, November 5, 2009

So this family wakes up at 6 am....

OK, so we did it … we are among the first of the general-ish public in Montréal to be vaccinated for H1N1. And the experience? Well, overall, I have to say: I really do love the entire underlying attitude here of respect for public health and community and doing the right thing overall. The worst offenders, strangely enough, is the media. They are bombarding the public with worries amplified to the point of terror and hysteria. It’s absurd. Because a mother, or any citizen for that matter, is concerned or has an experience that is for her discomfiting, does not mean there is either an inherent problem with the system, or widespread incompetence in play. It means that her particular situation may or may not have been handled optimally, though it is possible that the solution was best for the group and mildly inconvenient, possibly even mildly less individually-optimal for her or the health of her wards. This is possible, but it does not make for an outrage. It makes for anecdotal evidence of areas of improvement.

There is really a big difference between public health reporting and anecdotal outrage. Canada – proudly, and rightly so -- *is* about considering the public as a valuable entity; valuing the community. Why can the media not reflect this with understanding and pride? Cessing out anecdotes of extreme error is absolutely valuable to the extent that reporting on it furthers the public’s understanding -- that is, conveys important information -- to the public. Simply inciting terror and gratuitous outrage is irresponsible.

And I do believe there is quite the element of irresponsibility occurring in the public news reporting. To whit for days now there has been looping this mantra of outrage that families are waiting in line for hours only to discover that only a single family member, but not all, is eligible for the vaccination. This ditty is followed immediately with decries about how there is a shortage of vaccination: some in line are waiting only to discover there is not enough for them. Now … these two scenarios simply can’t be resolved in a situation where there is sufficient serum on order, but not enough at the front lines yet. The supply must be apportioned according to priority in order that the most at-risk both to themselves and the population at large, receive the vaccine first, in order to protect the general public. This is not an outrage. This is *GOOD* public health policy. Allowing all family members to vaccinated out of priority-order *results* in insufficient vaccine for those prioritized to receive it. It is irresponsible to report mutually incompatible situations as both being outrageous.

And now, to our experience. As a tangent and in the irresponsible department, let me add that the CBC was out in vengeance this morning – well, comparatively late in the morning, that is, 8 am work start-times needing to be respected. I understand from my children, who were sitting on the floor a little apart from the line to protect my immunocompromised child from the hoards of very young children present, that they were badgered by reporters to speak for the record into a microphone with a camera, when they certainly did not want to do this, and there was no adult present to supervise or consent to the interaction. I find this very upsetting but learned of it only as I had *just* reached the head of the line and we needed to proceed with the vetting process. There was no time for me to speak with the CBC though I would certainly have liked to have spoken to all of these issues on the record.

OK, so now to the experience itself. At the above time when we reached the start of the vetting process and I learned of this intimidation from my child, that was 8 am. We had arrived at the Cavendish mall at 6:50 am that (Thursday) morning. My feeling was that attending school is important, but vaccinating I is as well. If a little school needed to be missed in order to receive the vaccine, that would be fine. If a lot of school needed to be missed in order to be vaccinated at this time, the cost-benefit would tip toward leaving the line in favor of school. I decided that we would not alter our arisal routine but would change the order of ordinary procedure. That is, we would arise at 6 am as usual but forgo the usual morning music-practicing in favor of just leaving and doing, say, homework sitting on the floor of the mall. I decided it was important to choose a vaccination site that was indoors as we would be sitting for some time (hence, Cavendish mall). I decided to bring a towel for the kids to sit on apart from the line to try to limit their exposure to pathogens. I was happy that the vaccination schedule has been moved forward a day to Thursday from Friday, because this would give I a day to recover from the vaccination before her swim meet. When the injection was potentially Friday I asked I whether she wished to receive the vaccination if it jeopardized her swimming capacity for the next day. She made the decision herself to sacrifice her performance at the meet in favor of receiving the vaccine sooner than later: she is worried about this. So when the schedule was moved ahead a day I was happy to try all the little bit more harder to get in on Thursday as this might afford the additional day of cushion for her.

So, it’s Thursday morning, 6:50 am and the parking lot of the mall is crowded though not full. There is a big sign outside the appropriate door. These are both improvements over the day before when I went because the radio had been broadcasting from lines of people waiting for vaccines: as a stranger I was unable to determine whether the location they were mentioning was relevant to me or not. As it turns out, it was not; they were vaccinating health care workers on Wednesday only, but I did get a chance to figure out before I had kids in tow, where the mall was, which door to enter and also to sneak in a little bit of holiday shopping!

We arrive to a double line with orderly barriers snaking us around, with about 100 people ahead of us. I situate the girls in sight but about 50 feet away and proceed to sit on The Box (see another article about this!) knitting, scooting ahead as needed. A finishes her homework and The Box triples as a desk when needed (its first use being to hold all the myriad documents the bureaucracy here demands in hard-to-anticipate ways). An elderly gentleman with bright blue pinte walks the line and answers questions. He confirms that immunocompromised individuals and their families are part of the schedule today. I had earlier checked the pandemic Québec website for this information and had a hard time finding it. It seemed as if, oddly, this category might have been being dropped for today, though I couldn’t quite tell. I opted not to phone with the question because when I called two days ago, it was amply clear to me that the operators knew no more than I did; in response to my question about location and timing they simply looked up the same website I had at my disposal and could not resolve the ambiguities there. The gentleman further announced they were distributing coupons for 9 am at this point.

Fair enough still; we could get in line for the 9 am “seating” and it seemed to be possible they might get ahead of themselves and still let in the neck lozenge of people early, enabling the girls still to get to school reasonably close to starting time. So, then I make it to the head of the line and suddenly I is there whispering to me about reporters badgering her: no time to deal with that issue. I have my papers out and explain our status and am told I need to be interviewed by a nurse. *But* -- then they won’t give us a coupon and I am taken out of line. Huh? Hundreds are streaming through the line behind me, receiving coupons for that precious time-enough 9 am time. Grump. What’s to be done? I explain this isn’t making me happy, but they explain they aren’t interested; I need to see the nurse. That would seem to be the next step regardless of my “mood”, so I accede. There is another line (short) for the nurse where it becomes clear that they are pulling people from line who need to see the nurse *in advance* of the queue, and that despite my having confirmed I was in the right line for our circumstance, some people were being dealt with differently, presumably because they had a parallel queue to wait through. Double grump. The people ahead of my in the nurse-line had strolled in moments earlier though we had been in line 1.5 hours at this point. Ah well. I point out the inconsistency, hoping for someone to take note and “even” the experience for all, but I’m not sure anyone really quite understands the problem. The fact is, while “group 1” immunocompromised individuals are nominally to be vaccinated today, I see almost noone in this category present. Everyone there is a young child or family thereof or pregnant: there is an onslaught of tiny disease vectors everywhere, and – wisely! – a dearth of those likely to be felled by them.

Consequently the staff is more than a little confused by us as their directives have changed regarding immunization of the families of under 5 yo’s, and they wonder whether we should be treated as part of that group or not. My understanding is no, we are the family of immunocompromised individuals, and this is different. For one thing, we are few in number and won’t wipe out the supply the way families of all 5 yo’s would. For another, we would be critical society members to be keeping safe in deference to the communal-need to tamp down spread of the disease and minimize its effect. I point this out to the nurse who at first is reluctant to permit us all to be vaccinated. I would have deferred to her decision of course, but it was clear to me that she was working from a different set of rules focusing on a different problem: the onslaught of families. I pointed this out politely and rather to my surprise, she demurred, writing vaccination permission for us all. In the interim I had fetched A and I into the nurses realm, away from the badgering of the media. I should have done this immediately but wasn’t quite clear on what was happening when I was pulled out of line into another queue and was concerned that I needed to keep my place in the nurses’ queue even though I was becoming distantly separated from my children, who were being hounded!

So there we were, suddenly with permission in hand for vaccination. We had needed only our Régie papers (our cards have still not yet arrived), not proof of residence or address, no passport, no birth certificates or other niceties contained in The Box. Of course had I not had these at my disposal, we would surely have needed them. And with these permissions we were escorted … back to the coupon line where they were now handing out chits for 10 am! Oof. Because this would now be way-late for getting the children off to school. Had I known we could not enter until 10 am, I would have left the line earlier in order to get them to school. It was now approx 8:30 am; school starts at 9 am.

I articulated this “unfairness” (the quotes are to indicate that in the scale of things, this is hardly an unfairness of outrageous proportions, but here in this context, it was nevertheless frustrating) and the gentleman shrugged saying, “what can I do”? But the answer was clear enough – he should have given out the coupons when I arrived at the line. If we had been determined ineligible by the nurse subsequently, she could have taken back the coupons or simply denied us the permission sheet which would have been needed in any event. This was a procedural error, which I had pointed out at the time to several people, but they were unable to act upon the problem. Understandable, but frustrating.

The gentleman despite his grumpiness was apparently sympathetic, recognizing the error. And he said “here”, pulling out special-secret-get-out-of-jail-free coupons from his breast pocket. It emerges a little later that these are special reserved coupons for health care workers. He speaks to a woman (in French; I can barely follow the conversation) and she nods agreement and leads us to a large registration bank, whereupon we are blocked by another woman and there proceeds a slightly more heated, slightly acrimonious dialog in French that I *really* can’t follow, followed by the now-familiar grunt of accession and our way is cleared, only we are redirected to a holding pen to the side of the registration bank. I am relieved and more than happy to be simply settled among a group slated to get the vaccination at some point in the near future.

It turns out we are sitting amongst people who arrived at the line from 4:30 am on. These are an anxious collection. And we have inadvertently, therefore, jumped the queue considerably. I feel vaguely guilty about this, but I did try to get us simply to stay in-line as would have been fair, pointing out the problem-in-the-making to several individuals. I hadn’t intended to wind up ahead of our fair place. And some of the folks here are carrying on in such a scary fashion I worry what would happen should they comprehend our inadvertent advancement. When a woman came into the holding pen trying to explain what would happen from here on out, she got chewed out six ways to Sunday from six different directions. I was rather surprised at the snottiness of so many, particularly when, IMHO, things were actually set up remarkably well and proceeding remarkably smoothly. It is my considered opinion that the largest component of any possible problem really stems, again, from the way all of this is being reported, not any substantive issue.

OK, so we’re in this room with a lot of irked, cynical, negative people with piles of squirmy kids, and this person says numbers will start being called from B50 on. Except we’re number B40. So the person goes away, comes back with a correction it is to be B0-B50. Uproar: ‘this person was the first in line at 4:30 am and she has C51’ or some-such. People are mad, they can’t hear. Some wag decides it’s a good time to joke ‘the whole clinic has been canceled; everyone go home’…not. That is, this is not a funny joke, it’s rather akin to shouting “fire” in a crowded movie theater. Geesh. The things people find funny…. [this guy actually proceeded to say many, many more non-funny things in the queues to come]. So eventually it gets clarified that the earlier numbers were given to health care workers (hence our acquisition of one from the special-breast-pocket) and once the numbers start getting called, it transpires that we’re actually the only ones holding them. So much for that source of ire.

We’re ushered to the registration bank which is gigantic, which is impressive and gratifying. There are dozens of clerks and a supervisor running around resolving issues and an IT person and several other upper-level people. As there had been outside, too – many people running around and thinking about the situation; lots of backup help and people supervising – very good, truthfully. It is fortunate for this additional layer of expertise because again we are problematic as our cards are new; the clerk cannot find us. Fortunately I had verified we do in fact exist in the system and eventually his supervisor located our records but we needed to have more information entered before we could proceed. This took a lot of time and help assuage my guilt at having been scooted to the front of the line. I and A, through all of this, have been terrific.

Some time later we have exchanged our nurses’ notes for paperwork with a checklist searching for extenuating circumstances to vaccination. This is good. We are ushered into a clothed-in room for completing this checklist and listening to the nurse discuss contingencies and take questions. It comes out that people do not understand much at all about the vaccination or the process of figuring out how to administer it, dose, etc. But eventually this gets resolved and we’re ushered onward – but not before the denizens scuttle and scuffle for first-place priority in the little line that’s in this room, grumbling all the way. We’re already just 30 or so people so what difference it makes our relative place in this queue escapes me. I suspect the scene in the greater beyond is considerably wilder, as is subsequently confirmed.

So then we’re on our way, off to another queue awaiting some ladies who evaluate our answers. She wants to know why we’re all being vaccinated and it appears there is no space for her to acknowledge our category of immunocompromised – no wonder they are unsure how to deal with us. True, it should all have been administered in a doctor’s office, but ignoring us isn’t going to help either!

Eventually we’re off to the last stop which turns out at last to be the vaccination setup. There are eight long tables with a nurse seated at the head of each one supervising two people on either side actually administering the vaccination. It is clear these individuals are less skilled and there is some confusion about A’s age, which is 9y4m, evidently close enough to the 10 year cutoff to provide confusion, or something? I dunno, but whatever…. Poor A is so worried during the wait her eyes are puddles of liquid nervousness. But the shot is really not a big deal at the end of it all. It doesn’t hurt much, it’s a small needle, it’s over before you know it. At the end of the day, the biggest irritation is that while I told the girls to wear tshirts so the vaccination would be quicker, *I* forgot to wear one! It’s obviously not really a big deal, but my turtle neck’s sleeve is just a teensy bit baggier as a result of the experience. Not a big deal, really. Rather a sweet memory of the morning.

The girls returned to school at 9:15am. A was furious about the tardiness. Geesh – if only she knew! When we returned to the main lobby it was shoulder-to-shoulder with hundreds and hundreds of people. I don’t know how long their wait will be, but it seems likely it will be longer than the 3 hours it took me door-to-door.

I personally feel very grateful to the Canadian health service for a Herculean effort actually conducted quite well. That’s my perspective at least.