Wednesday, 31 March 2010

Note to my Patients

Dear Patients

When you come to my Accident and Emergency department complaining of chest pain and I ask if you have any history of heart problems could you please tell me the truth. When you say "No" I assume you havent had those two myocardial infarctions you will later tell the doctor about. It doesnt matter that they were "only minor" when you lie to me it scraps whatever credibility I may have as a student nurse with the doctors. When a patient is diabetic we know to double the number of cream cakes they say they have eatten today, when they are smokers we know to treble the number of cigarettes they claim to have smoked, and with alcoholics its always a factor of four. This should not be the case with heart attacks.

When you do things like this it makes me angry, and there is only one way my professional armour allows me to deal with that anger. So when you lie to me and make it look like I cant take an accurate history do not become upset when I become extremely sarcastic. Please remember when you lie to me, that although I may not have a fancy stethoscope around my neck my fraying patience is the one controlling your oxygen supply.

Yours ever so sincerely

Disgruntled Student Nurse

Dark Place

I was going to write about a shift I worked recently which was woefully understaffed. I was going to write about issues concerning patient and staff safety. I was going to let off steam regarding the complete absence of the most fundamental of ward equipment on this ward. I could go on.

In fact I did write about the above, I even posted it. Then I deleted it. Its rare that I am left to feel this helpless. No serious harm came to anyone during the shift. So it would not be considered a priority. Infact we hit all our targets. I considered writing an incident report about this shift but the people who read incident reports are the people who put myself and my colleagues in that situation. They are also the people I was shouting at all day to no effect. When a patient or member of staff gets hurt the incidents will be noted by those high enough up the chain of command to change things. I just hope that it doesnt take a death.

Tuesday, 23 March 2010

My First - Arrest

Technically this wasnt my first arrest, but it was my first arrest working on A&E and as a student nurse this meant I had a greater potential to effect the outcome of this arrest.

I was working in A&E resus with my mentor, and the red phone(commonly called the bat phone) rang. This phone is only dialed by ambulance crews telling us they are bringing a majors or resus patient. We took the details of the patient as follows -

44 Year old. Male. In cardiac arrest on arrival. Non-shockable rhythm. Resuscitation started on arrival. Four previous MI's. High BMI. ETA 4 minutes.

There were other details but the purpose of this post they were irrelevant. I started preparing the space we would bring hte patient into. Turning on the AED(defib). Making sure the cardiac monitor, blood pressure and pulse oximeter cables were all untanlged and the machine they were all connected to was on. I cracked open a high flow o2 mask and started it on 15L. Whilst I was doing this my mentor was beeping the crash team. We then gowned and gloved up. I made sure the board was clear and the board markers were working. Scribing is vital to clear, fluid resus attempts. Just before the ambulance crew came running through the emergency doors and the crash team came running down the corridor, my mentor looked at me, smiled, told me to take a deep open breath and remember this "No matter what happens, even if you do everything wrong, this man is dead, nothing you do can make the situation any worse for him". I still dont fully understand why but his words have come to my mind during every arrest I have attended since and they have kept me calm.

The resusciation attempt wasnt as hard as I was expecting, I stayed calm, and there was very little thought involved. My mentor took charge of everyone present, even the doctors. My body reacted to the voice of command and I found everything else was muscle memory and instinct. The patient did not survive however a study performed in london a few years ago suggested that when it comes to pre-hospital arrests, even if the crew arrive quickly and a first aider starts cpr as soon as the arrestee drops there is still only a 1 in 185 chance that the patient will survive to be discharged from hospital. I would imagine the odds are a lot worse for people who arrest with a non-shockable rhythm(Asystole or PEA). The hard part is thanks to all these medical drama's on tv every patients relatives expect you to raise the dead.

Saturday, 13 March 2010

My First - Death

I am back on placement, my final placement. After this I qualify and become a real nurse. The strange thing is I have spent the last two and a half years rocking every placement, walking around MY hospital with a confidence I have never really felt before(and in most of the situations i've been in over the last three years an outward confidence I didnt really feel). I have been dying to qualify, raring to go. Now I am nearly there I am petrified. I think it was Socrates who suggested something along the lines of - the more you learn the more you come to realise you know nothing.

Now I'm nearing the end of what has been a strange combination of the longest and shortest three years of my life I cant help but look back at the defining moments of my training. In this case the first patient who died under my care. This happened in my first year on my first placement, an elective orthopaedic ward. The patient was only on the ward due to lack of beds on the trauma orthopaedic ward. He had come in following an RTC, he had been stablised in A&E and went into surgery to repair numberous fractures and ruptured vessels. When they had finished with him he was transfered to my ward and remained unstable, his blood pressure constantly dropping, pulse rising and dropping with an irregular rhythm and the patient hadnt been conscious since A&E and a DNR order was signed by his NOK with his permission on presentation to A&E. I was working the night shift about a month into the placement, one of the other nurses had checked on him twenty minutes previously. I went in to check on him largely because there was nothing else to do. He was dead, my first dead patient. He looked just the same, I'd heard all these stories about how people change in death but I had to check for a pulse and watch for breathing to make sure. I walked out of the room and told the nurse. She knew he was taking his last breaths when she'd been in earlier, she just shrugged it off. Then it hit me, the shame that all I was thinking about was how hard his death was for me, the anger at her indifference to the fact someone had just died less than ten feet from where we stood(which I now understand is a defence mechanism and one that I use myself).

Two years on I've worked in A&E, I've worked on many acute medical wards and I have had many patients die under my care. The only way you can survive the reality of acute nursing is to distance yourself from the deaths, and make sure you did everything you could so you know there was nothing more you could have done and their death wasnt your fault.