It has come to my attention that there are one or two expectations in Nursing and Medicine which can not be met.
The first is impartiality. A Nurse, Patient bond is essential for adequate delivery of care. The second you meet a patient small connections occur, you share a joke, tell a story. Little things that put the patient at ease and allow you to get a read on what kind of person they are and get a baseline personality so you can determine any change. However Nurses are expected to be impartial in delivery of care. This is impossible to do once you have made that vital bond. The patient is no longer "Bed D3", they have a name, This again is important because one of the little known roles of a Nurse is to be a patients advocate. A nurse is expected to analyse the patient care based on his or her training and ensure that the patient is receiving the best possible care.
This moves me on to my second point. "Informed Consent". This is a hideous concept. It requires a patient to understand concepts Doctors spend five years in med school trying to get their head around. The patient is then expected to make a decision that will generally effect the path of the rest of their life. The nurses advocacy is largely beneficial here however a Nurse can only explain the procedures to the patient, they can quote facts and figures, they can not express opinion.
Largely a patient is required to have blind faith in their Doctor. And why not? the Doctor is a highly trained medical professional who is working in a system which minimises the risk to the patient. Unfortunately the doctor is only human, mistakes and error in judgment happens. This is not a reason to lose faith in the doctor(s) unless it is a regular occurrence. I believe this is why the Doctor has to appear arrogant, and distant. If the doctor shared the same bond with the patient as a nurse the patient would see that the doctor is just a normal human being.
To conclude. Impartiality should only apply to Doctors because it already does. And Informed Consent is a ridiculous notion.
Wednesday, 30 April 2008
Tuesday, 29 April 2008
Angry
Once again I find myself breathlessly angry. I am a regular reader of Random Acts of Reality. Recently Tom Reynolds spoke on Radio 5 regarding This Issue. During this time Paramedics, and EMT's were being called cowards and infact compared to nazi's for following orders. If you arrive at the scene of a violent crime, you HAVE to wait for the police to arrive. You do not rush in there and get yourself stabbed. What good is a highly qualified , highly trained, DEAD paramedic? Yes medical staff have a duty of care. however they are not trained, or equipped to handle these situations, thats what the police are for. And even the police have strict guidelines on how to proceed. The first caller referred to paramedical professionals as nazi's.
I appreciate this post isnt terribly clear but I am so angry my hands are still shaking.
I appreciate this post isnt terribly clear but I am so angry my hands are still shaking.
Monday, 28 April 2008
Evolution and Bacteria
As far as modern science can ascertain the first organisms to appear on this planet were bacteria. And although bacteria are prone to mutation very little 'evolution' has occurred for as long as such things have been recorded. This is phenominal given they multiply exponentially. This means if you have one organism and it divides into two, and those two divide into two each. every generation you have double the number of the previous generation. Statistically the more times a living organism creates a new generation the chances of mutation increase, This mutation will then be passed on to all subsequent generations. These mutations are in some respects what we call 'evolution'. Given the speed at which bacteria create new generations in the space of a year we have ample time to study the changes over hundreds, thousands, millions and even billions of generations. We are quite confident very little 'evoltion' occurrs. This may be due to a key factor in evolution. If you have no hindering attributes there is is nothing to dilute out.
When we grow bacteria in agar (a gel of nutrients optimised for bacterial growth) and apply optimal heat. There are several phases the colony goes through.
1.Lag Phase, this is where the bacteria have just been introduced to the new conditions and take a little time to start dividing.
2.Log(arithmic) Phase. This is where the bacteria are dividing optimally and will reach peak rate of division.
3.Stationary Phase. This is where the toxins the bacteria produce have built up and are killing off the bacteria at an equal rate to the generation time.
4.Death phase. The toxins have mounted and are now killing the bacteria at a greater rate than generation time.
This assumes unlimited nutrition for the bacteria, however given the limitations on space the colony eventually eradicates itself. Now lets try and apply this to humans. Our population may not be exponentially increasing but it is certainly increasing at a steady and uncontrolled rate. We have limited space and nutrition available for our numbers. Eventually our waste will consume us. This is the greatest argument I can think of for going 'green'. It wont avert this fate but it stands a good chance of buying time.
Additionally if we assume as many do that the reason bacteria have changed little since the dawn of recordable time(we know this from ice samples extracted from the arctic and antarctic) is because they have little need to evolve past their current optimal state. This is directly related to how hardy they are. Humans however are still evolving, at an incredibly retarded rate. Modern medicine and technological advances eliminate 'survival of the fittest'. We have no preditors, and we have medicines for most ailments that would have eliminated the more vulnerable members of our species. This would suggest that we are far less able to survive our own fate.
Downsides to everything I've just said -
bacteria can survive with just one organism, Humans require two organisms short term, but a more diverse gene pool long term.
I make no apologies for my species. A random genetic mutation (or a series of) left us with aposable thumbs, I dont feel bad for eatting species that didnt develop this trait. Thats just nature.
I have had to simplify the science here greatly in order to make it digestible.
I will be posting more on this at a later time. I've just spent the day reading journals and my brain is fried. I hope this doesnt show too much in my writing.
When we grow bacteria in agar (a gel of nutrients optimised for bacterial growth) and apply optimal heat. There are several phases the colony goes through.
1.Lag Phase, this is where the bacteria have just been introduced to the new conditions and take a little time to start dividing.
2.Log(arithmic) Phase. This is where the bacteria are dividing optimally and will reach peak rate of division.
3.Stationary Phase. This is where the toxins the bacteria produce have built up and are killing off the bacteria at an equal rate to the generation time.
4.Death phase. The toxins have mounted and are now killing the bacteria at a greater rate than generation time.
This assumes unlimited nutrition for the bacteria, however given the limitations on space the colony eventually eradicates itself. Now lets try and apply this to humans. Our population may not be exponentially increasing but it is certainly increasing at a steady and uncontrolled rate. We have limited space and nutrition available for our numbers. Eventually our waste will consume us. This is the greatest argument I can think of for going 'green'. It wont avert this fate but it stands a good chance of buying time.
Additionally if we assume as many do that the reason bacteria have changed little since the dawn of recordable time(we know this from ice samples extracted from the arctic and antarctic) is because they have little need to evolve past their current optimal state. This is directly related to how hardy they are. Humans however are still evolving, at an incredibly retarded rate. Modern medicine and technological advances eliminate 'survival of the fittest'. We have no preditors, and we have medicines for most ailments that would have eliminated the more vulnerable members of our species. This would suggest that we are far less able to survive our own fate.
Downsides to everything I've just said -
bacteria can survive with just one organism, Humans require two organisms short term, but a more diverse gene pool long term.
I make no apologies for my species. A random genetic mutation (or a series of) left us with aposable thumbs, I dont feel bad for eatting species that didnt develop this trait. Thats just nature.
I have had to simplify the science here greatly in order to make it digestible.
I will be posting more on this at a later time. I've just spent the day reading journals and my brain is fried. I hope this doesnt show too much in my writing.
Interesting
Recently a friend directed my attention to This Article knowing my interests and background lay in critical care. I found the article interesting enough to analyse here.
"OPALS project -- likely the world's most important research into the care provided to patients before they reach hospital". Admittedly a soft point for me to start my argument on. No British authority recognises OPALS(Ontario Prehospital Advanced Life Support). And this is for good reason, Canadian medical authorities do not have the financing, legal privileges, or experience to carry out any detailed studies in comparison with the authorities of the US and United Kingdom.
Secondly prehospital conditions are radically different in Canada. Their EMT's are trained based on different (yet seemingly equally as effective) protocols. Their ambulances and terrain would also effect the stability of a trauma patient. However my largest point is that there is a massive distance between hospitals throughout most of Canada, even in their urban centers. Where UK ambulances have an 8 minute ORCON(Operational Research Consultancy) targets for all catagory A calls. Most Canadians would be lucky if they were injured within an hour of the nearest ambulance. I believe the figures this study has collected should implement a reconsideration of long-haul ambulance journeys with a trauma patient, however there is no suggestion that the study has taken into consideration duration.
"OPALS project -- likely the world's most important research into the care provided to patients before they reach hospital". Admittedly a soft point for me to start my argument on. No British authority recognises OPALS(Ontario Prehospital Advanced Life Support). And this is for good reason, Canadian medical authorities do not have the financing, legal privileges, or experience to carry out any detailed studies in comparison with the authorities of the US and United Kingdom.
Secondly prehospital conditions are radically different in Canada. Their EMT's are trained based on different (yet seemingly equally as effective) protocols. Their ambulances and terrain would also effect the stability of a trauma patient. However my largest point is that there is a massive distance between hospitals throughout most of Canada, even in their urban centers. Where UK ambulances have an 8 minute ORCON(Operational Research Consultancy) targets for all catagory A calls. Most Canadians would be lucky if they were injured within an hour of the nearest ambulance. I believe the figures this study has collected should implement a reconsideration of long-haul ambulance journeys with a trauma patient, however there is no suggestion that the study has taken into consideration duration.
Saturday, 26 April 2008
Full Moon
Ok so it must be a full moon because the world out there tonight is full of what we in healthcare call whack-jobs. As some of you may have deduced I have just come off a duty with St John Ambulance,
Lets start with a tale of extreme parental negligence, A gentleman walked up to us and indicated to his 10 year old son who was shoeless and using crutches to support a very obviously injured ankle. He asked us what was best for a sprained ankle. We asked how the lad had hurt himself. "he fell off a stage". I recommended rest, ice, compression and elevation. It surprised me that the doctor they saw hadnt recommended this also, as they were walking away I noticed the crutch wasnt hospital issue. This child had an ankle with all the signs of a break and had not been taken to see a doctor. This played on my mind and during hte intermission I tracked down the father and strongly suggested he take his child to see a doctor as soon as was convenient. My problem here isnt with a father who dislikes A&E and walk-in clinics on a saturday. Its with a father who suggests his child walk around shoeless using a walking aid that was far too large for him.
Next up, during the same duty was a man who worked at the venue. He wanted to clear room for the ice creams to be sold at the back of the auditorium, but rather than asking any of us to move so this could be accomplished quickly and efficiently before the intermission, he just grabbed my arm.....and pulled.
Many of you know that I dont like being touched at the best of times, even by people I like, its just my thing. However this was rude, and could easily fall under the catagory of assault. So I informed the gentleman in question that we WOULD be stepping outside of a discussion where upon I informed him that were he to touch me or any of my colleagues in such a manner again the following events would not be his fondest memories. He apologised half-heartedly and walked away. This irritated me even more, however his superior was sat in the stairwell unbeknownest to either of us. The usher approached me later in order to apologise more sincerly, from this I assume his boss had had a word with him. I told him it would be in his best interests to stop talking and walk away.
I AM NOT HAVING A GOOD DAY!
Lets start with a tale of extreme parental negligence, A gentleman walked up to us and indicated to his 10 year old son who was shoeless and using crutches to support a very obviously injured ankle. He asked us what was best for a sprained ankle. We asked how the lad had hurt himself. "he fell off a stage". I recommended rest, ice, compression and elevation. It surprised me that the doctor they saw hadnt recommended this also, as they were walking away I noticed the crutch wasnt hospital issue. This child had an ankle with all the signs of a break and had not been taken to see a doctor. This played on my mind and during hte intermission I tracked down the father and strongly suggested he take his child to see a doctor as soon as was convenient. My problem here isnt with a father who dislikes A&E and walk-in clinics on a saturday. Its with a father who suggests his child walk around shoeless using a walking aid that was far too large for him.
Next up, during the same duty was a man who worked at the venue. He wanted to clear room for the ice creams to be sold at the back of the auditorium, but rather than asking any of us to move so this could be accomplished quickly and efficiently before the intermission, he just grabbed my arm.....and pulled.
Many of you know that I dont like being touched at the best of times, even by people I like, its just my thing. However this was rude, and could easily fall under the catagory of assault. So I informed the gentleman in question that we WOULD be stepping outside of a discussion where upon I informed him that were he to touch me or any of my colleagues in such a manner again the following events would not be his fondest memories. He apologised half-heartedly and walked away. This irritated me even more, however his superior was sat in the stairwell unbeknownest to either of us. The usher approached me later in order to apologise more sincerly, from this I assume his boss had had a word with him. I told him it would be in his best interests to stop talking and walk away.
I AM NOT HAVING A GOOD DAY!
Healthcare Assistants
I subscribe to the Nursing Standard. A very good publication with many articles of both educational and thought provoking value. One such article appeared on page 9 of the latest issue. Should student nurses be learning from Healthcare Assistants? I felt this topic warranted more than the small paragraph it was given.
First off lets breakdown the structure of a ward. You have the Ward Manager who is the top nurse, then Senior Nurses, Junior Nurses, Clinical Nursing Assistants, Senior Healthcare Assistants and Finally Healthcare Assistants. Each of the latter three are healthcare assistants. A healthcare assistants role is to aid the nurses where possible but also perform tasks that directly benefit the patient, for example aiding the patient with the 12 activities of daily living(Roper, Logan and Tierney). These tasks are also expected of nurses however nurses have other duties which mean they can not do this all the time.
A student nurse needs to learn all of the clinical duties of his or her role, However I am certain that before you can learn to be a nurse you must learn to be a healthcare assistant. This doesnt mean you wash someone once and say 'thats it I can now move on'. Many student nurses feel that healthcare assistant work is beneath them, this is insane as a seasoned healthcare assistant is likely to a lot more than you will by the end of your training. I was formerly a senior healthcare assistant so my judgement may be a little askew.
On my first placement the one man I learned the most from, was a clinical nursing assistant. The nurses taught me the clinical skills i required but a trained ape can give a subcutaneous injection, a huge amount of what it is to be a nurse is in your attitude and how you approach every challenge you are faced with. This clinical nursing assistants key trait was to look at an obstacle mutter 'improvise, adapt, overcome' and develop an incredible efficient solution. Without realising it, working with this man for nine weeks left me with the same trait.
I honestly believe that on a student nurses first placement, their mentor should be a healthcare assistant. The tasks that the student would learn here are the foundation of good nursing practise.
First off lets breakdown the structure of a ward. You have the Ward Manager who is the top nurse, then Senior Nurses, Junior Nurses, Clinical Nursing Assistants, Senior Healthcare Assistants and Finally Healthcare Assistants. Each of the latter three are healthcare assistants. A healthcare assistants role is to aid the nurses where possible but also perform tasks that directly benefit the patient, for example aiding the patient with the 12 activities of daily living(Roper, Logan and Tierney). These tasks are also expected of nurses however nurses have other duties which mean they can not do this all the time.
A student nurse needs to learn all of the clinical duties of his or her role, However I am certain that before you can learn to be a nurse you must learn to be a healthcare assistant. This doesnt mean you wash someone once and say 'thats it I can now move on'. Many student nurses feel that healthcare assistant work is beneath them, this is insane as a seasoned healthcare assistant is likely to a lot more than you will by the end of your training. I was formerly a senior healthcare assistant so my judgement may be a little askew.
On my first placement the one man I learned the most from, was a clinical nursing assistant. The nurses taught me the clinical skills i required but a trained ape can give a subcutaneous injection, a huge amount of what it is to be a nurse is in your attitude and how you approach every challenge you are faced with. This clinical nursing assistants key trait was to look at an obstacle mutter 'improvise, adapt, overcome' and develop an incredible efficient solution. Without realising it, working with this man for nine weeks left me with the same trait.
I honestly believe that on a student nurses first placement, their mentor should be a healthcare assistant. The tasks that the student would learn here are the foundation of good nursing practise.
Thursday, 24 April 2008
Off Topic
Ok so this is a little off topic for me, but take a look at this -
http://tech.slashdot.org/tech/08/04/23/1714254.shtml
Firstly its good to know that world government scientists are still geeks(much like myself). Secondly.....isnt this just a railgun? not that it isnt big and scary .....but its a railgun.
http://tech.slashdot.org/tech/08/04/23/1714254.shtml
Firstly its good to know that world government scientists are still geeks(much like myself). Secondly.....isnt this just a railgun? not that it isnt big and scary .....but its a railgun.
Wednesday, 23 April 2008
Student Life
It appears one or two of my colleagues and friends are starting nursing this year. So I thought I'd write this to offer some advice....and warnings.
First off you will not have a life, student nurses who go out drinking every night and turn up on placement hung over drop out very quickly. Lets face it even being hungover whilst in charge of a patients care is plain wrong.
Secondly, on placement you will be given as much responsibility and training as you work for. If you are sat there waiting for your mentor to push you and force opportunities on you, you're a fool. If you hear about an upcoming procedure you want to see, you ask to see it. Request time off ward to spend time with the cardio team or the physios. Each placement is a minimum of 8 weeks long, you'll have plenty of time on ward but its vital you experience as much as possible.
Do not get involved with the petty student factions. Most of the people on your course will be catty, bitchy 18 year old girls who try to draw you into their arguments. They will also be very friendly with you until you start doing better than them.
At Southampton more than half the students end up dropping out, most of these do so in the first year. Its a hard course and a lot of people are there for an easy ride.
Reputation matters, on placement its vital that your attitude and manner are professional and friendly. At the end of the day you'll be spending 3 years at this hospital and they are small enough so that word spreads, when you qualify your reputation within the hospital means a lot more than what award you qualified on or how well you did in your life sciences exam.
Lastly, I strongly recommend you buy the following books, some are considered mandatory course texts, most arent.
Human Anatomy and Physiology(Seventh Edition) - Elaine N. Marieb, Katja Hoehn
British National Formulary(latest edition?)
The Royal Marsden Hospital Manual of Clinical Nursing Procedures(sixth edition) - Lisa Dougherty, Sara Lister
Nursing Practice Hospital and Home: The Adult - Margaret F. Alexander, Josephine N. Fawcett, Phyllis J. Runciman
First off you will not have a life, student nurses who go out drinking every night and turn up on placement hung over drop out very quickly. Lets face it even being hungover whilst in charge of a patients care is plain wrong.
Secondly, on placement you will be given as much responsibility and training as you work for. If you are sat there waiting for your mentor to push you and force opportunities on you, you're a fool. If you hear about an upcoming procedure you want to see, you ask to see it. Request time off ward to spend time with the cardio team or the physios. Each placement is a minimum of 8 weeks long, you'll have plenty of time on ward but its vital you experience as much as possible.
Do not get involved with the petty student factions. Most of the people on your course will be catty, bitchy 18 year old girls who try to draw you into their arguments. They will also be very friendly with you until you start doing better than them.
At Southampton more than half the students end up dropping out, most of these do so in the first year. Its a hard course and a lot of people are there for an easy ride.
Reputation matters, on placement its vital that your attitude and manner are professional and friendly. At the end of the day you'll be spending 3 years at this hospital and they are small enough so that word spreads, when you qualify your reputation within the hospital means a lot more than what award you qualified on or how well you did in your life sciences exam.
Lastly, I strongly recommend you buy the following books, some are considered mandatory course texts, most arent.
Human Anatomy and Physiology(Seventh Edition) - Elaine N. Marieb, Katja Hoehn
British National Formulary(latest edition?)
The Royal Marsden Hospital Manual of Clinical Nursing Procedures(sixth edition) - Lisa Dougherty, Sara Lister
Nursing Practice Hospital and Home: The Adult - Margaret F. Alexander, Josephine N. Fawcett, Phyllis J. Runciman
Blood
The wound drain I mentioned yesterday was a Bellovac Drain although I am sure there are other drains out there that do the same thing. This drain is inserted whilst the patient is still on the operating table. The idea is to drain the haematoma from the wound site. This is effectively just pooled blood and it is in question weather or not draining this blood does much. This blood is no longer part of the circulating volume and this isnt supplying any tissue. Once the blood is drained into the bag a nurse can just replace the bag and hook the blood filled back up to a standard IV for transfusion. Obviously you require a certain amount of blood before its worth replacing the bag, anything less than 120ml and it will probably get lost in the IV tubing.
In my opinion this is one of the greatest recent achievements of medical science. I am still in awe of the fact we can reinfuse a patients own blood from a wound drain.
Sometime a patient wont bleed enough to warrent transfusion, this largely depends on the operation and the surgeon involved. Total Knee Replacements always bleed well. However for those who dislike transfusions there are other options for boosting your circulating volume. First off you hang a bag of saline just to keep the volume in the vessels high, and then you can administer a drug called erythropoietin. The athletes among you might refer to this as Epo. Its a drug designed to increase the rate at which the body produces red blood cells. This is of particular interest to athletes as the mood red blood cells you have circulating, the more haemoglobin, which means more oxygen, which means the muscles are better fed during periods of heavy exercise.
In my opinion this is one of the greatest recent achievements of medical science. I am still in awe of the fact we can reinfuse a patients own blood from a wound drain.
Sometime a patient wont bleed enough to warrent transfusion, this largely depends on the operation and the surgeon involved. Total Knee Replacements always bleed well. However for those who dislike transfusions there are other options for boosting your circulating volume. First off you hang a bag of saline just to keep the volume in the vessels high, and then you can administer a drug called erythropoietin. The athletes among you might refer to this as Epo. Its a drug designed to increase the rate at which the body produces red blood cells. This is of particular interest to athletes as the mood red blood cells you have circulating, the more haemoglobin, which means more oxygen, which means the muscles are better fed during periods of heavy exercise.
Tuesday, 22 April 2008
Suicide in the Name of God
Ok my first post is one that will likely ruffle a few feathers. Jehovahs Witnesses and elective surgical procedures. The following is not based on any patient I have known or ever heard of, the following is completely hypothetical and I accept no responsibility for any similarity between the following and any real patient.
A victim of a car crash or some other incident beyond their choosing is brought into A&E and requires a blood transfusion. This patient is a Jehovahs Witness, and as a result this patient refuses the vital transfusion in the name of their belief. I actually have no problem with this, infact on many levels I admire it, the level of faith required to choose death in this situation is incredible and certainly far beyond me.
My issue comes when a patient requires a total hip replacement, an entirely elective procedure which usually results in the need for a blood transfusion. This patient may be in pain but they have elected to undergo a surgery for a non-life threatening condition. The blood transfusion would be required to stabilise the patient after surgery as a certain amount of blood loss is expected. This patient is expecting the doctors, nurses, healthcare assistants and physiotherapists to work much harder. Unfortunately a consulting orthopaedic surgeon can not turn down this patient in pre-assessment based on their religion. This would be 'politically incorrect'.
What irritates me is there are certain wound drains available which drain the patients blood from the wound site during and after the operation and this blood can then be reinfused. It is the patients own blood so there is no risk of a transfusion reaction and In theory the blood has never left the circulation, it has just taken a detour. This is acceptable to some(few) Jehovahs Witnesses so I have no problem with such people. However an argument raised against it is that the blood has technically left the body.
Surely if they are willing to die to prove their beliefs they could take this one step further and live their lives in pain with decreased mobility.
A victim of a car crash or some other incident beyond their choosing is brought into A&E and requires a blood transfusion. This patient is a Jehovahs Witness, and as a result this patient refuses the vital transfusion in the name of their belief. I actually have no problem with this, infact on many levels I admire it, the level of faith required to choose death in this situation is incredible and certainly far beyond me.
My issue comes when a patient requires a total hip replacement, an entirely elective procedure which usually results in the need for a blood transfusion. This patient may be in pain but they have elected to undergo a surgery for a non-life threatening condition. The blood transfusion would be required to stabilise the patient after surgery as a certain amount of blood loss is expected. This patient is expecting the doctors, nurses, healthcare assistants and physiotherapists to work much harder. Unfortunately a consulting orthopaedic surgeon can not turn down this patient in pre-assessment based on their religion. This would be 'politically incorrect'.
What irritates me is there are certain wound drains available which drain the patients blood from the wound site during and after the operation and this blood can then be reinfused. It is the patients own blood so there is no risk of a transfusion reaction and In theory the blood has never left the circulation, it has just taken a detour. This is acceptable to some(few) Jehovahs Witnesses so I have no problem with such people. However an argument raised against it is that the blood has technically left the body.
Surely if they are willing to die to prove their beliefs they could take this one step further and live their lives in pain with decreased mobility.
Welcome
Welcome one and all to my new blog. I intend to use this area to rant about all things medical.
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