Shorthand

Pt biba following RTC. 3xPCW around R 4-5 IC spaces. ?# R NOF as S+R of limb and dec ROM. GCS 12. MEWS of 5 due to rr 22, pr 114 and systolic bp 98. 15l o2 via non-rebreathe, maintaining sats 89%. ECG done and shown to dr. IV morphine administered as per prescription chart. CXR, Abdo XR and Hip XR ordered. Pt a/w tx ESAU.


This patient was an absolute wreck, I was helping work on him. Later that shift I found this nursing note written by a charge nurse also working on that patient. I can understand everything written there but I feel nursing notes should be a little clearer. The translation is as follows -

Patient brought in by ambulance. Three penetrating chest wounds around the right fourth and fifth intercoastal spaces. Query fractured right neck of femor as there is shortening and rotation of the limb and decreased range of motion. Glasgow coma scale of 12. Modified Early Warning System score of 5 due to resp rate of 22, pulse rate of 114 and systolic blood pressure of 98mmol. Patient on 15 litres of Oxygen via non-rebreathe mask and maintaining oxygen saturation of 89%. Electrocardiograph done and shown to doctor. Intravenous morphine administered as per prescription chart. Chest X-Ray, Abdominal X-Ray and Hip X-Ray requested. Patient awaiting transfer to emergency surgical assessment unit.

A&E: Day One

Sorry for my lack of posts recently I've been putting a bit of time into preparation for my new placement. I am now spending eight weeks on Accident and Emergency. This is very much where I want to be career wise.

For my first day I was working majors. This is where patients go if they have a serious injury or illness and will probably require inpatient admission. My first patient was a known alcoholic in his mid-fourties who was found in the middle of a road unconcious with some very nasty grazes down his arm. Grazes dont sound that bad however he was losing about a pint of serous fluid(clear body fluid) every few minutes. He had taken most of the layers of skin off his. Obviously the key here was to dress the wound and get as much saline into him as humanly possible, we also gave him various vitamins to ease the effects of the alcohol withdrawl. All in all a really good first patient.

We also had a couple of road-traffic collisions(RTC's) one of whom was triple-immobilised by the ambulance crew(neck colar, head blocks and straps all over hte body). We had to get an x-ray of his c-spine before we could remove any of this. This shouldnt be too hard but we are fairly sure he dislocated his shoulder as well so it was damn near impossible to get a clear picture of the last cervical(that spelling doesnt look right but my brain is melting so it will do) vertibrae.

All in all an exciting first day.

Productive Ward

Many trusts seem to be adopting a fairly interesting new system known as Productive Ward. This is where for one shift on a regular basis a nurse is taken off of his/her clinical duties and sits down and trys to think of ways to make the ward more productive. Something as simple as moving the commodes nearer the door in the sluice room so that it takes a fraction of a second less time to get the commode to the patient(which apparently adds up).

A ward in bath has made the news because rather than having the one set of keys for the drugs trolley floating around different members of staff depending on who used them last they keys are now locked up in a safe and every member of staff is given a key for the safe. The benefit here is that they can now avoid a very regular occurrence on all wards - a member of staff has gone home with the keys in their pocket and has now got to be dragged back in because none of the patients can get their medications. I would strongly argue that the downside of this system is that when they keys are floating they are always in the possession of a member of staff, someone relevant always knows where they are. If they are in a safe they are unobserved for long periods of time, added to which there are now keys for the safe all over the place. This seems far less secure and potentially very dangerous.

All in all the productive ward scheme seems to be keeping peoples attention on the importance of ward efficiency however I am not certain that the changes made are really making a difference. Another drawback is the nurse working a productive ward shift has to do it on the ward. If you are a nurse on your ward you are going to get roped into checking IV's, answering buzzers, and generally chipping in during those day to day crisis moments on the ward(which frankly I would prefer). This wouldnt be too bad if most wards didnt insist that a nurse in a productive ward shift has to wear plain clothes(no uniform).

However it does make you think how much time and energy is wasted at work through tiny inefficiencies. It does all accumulate.

On a side note I recommend you guys take a look at This Site. Its full of little educational flash games. My favourite is the blood typing game.

Failure

In this profession you standardise you're level of success or failure based on how many patients are alive when you leave the ward. If you have worked a shift and none(or in critical care very few) of your patients have died then you mentally tick that off as a successful shift.

Many wards at any one time have patients who are palliative, they are dying and there is nothing that can be done medically to prevent this. Fortunately there are care pathways(protocols) in place for any patients who meet very specific criteria. This takes a lot of the difficult decisions out of the hands of doctors, nurses and the patients family. The standard care pathway in my trust is the Liverpool Care Pathway. Once a patient has started on this care pathway their treatment is purely for comfort. Analgesics, Anti-emetics, etc are administered
more or less constantly via a syringe driver. A device that slowly injects medications over a given period so rather than a patient getting a dose of morphine for their pain at 1300 and needing another dose at 1500, the driver releases the same dose into the body constantly over x amount of hours. This not only means the patient is constantly receiving pain and sickness relief but the nurse doesnt have to wake the patient up every three hours to administer the drug.

Once a patient is on the LCP and non-essential medications are discontinued(pretty much anything they wont die immediately if you take them off) and their observations are either ceased or taken only once a day as it is an uncomfortable thing to do to a patient but absolutely necessary for a patient who has a chance of recovery. In patients with no chance of recovery whats the point of waking them up at 0500 every morning to take their blood pressure, pulse, oxygen levels, etc. On a regular basis the patient is assessed for pain, agitation, nausea,
breathlessness, etc and if there is any variance on these then the medication the patient is on is adjusted so that they are as comfortable as possible.

This phrase always made me laugh "as comfortable as possible". The patient is dying, they are scared, exhausted, probably in pain. What we make the patient isnt anywhere near comfortable. And to add to the discomfort we take them off fluids and food and of course they are bed bound so they will be cathatarised. Ethically is this the right thing to do? they are dying and food, fluids, etc will prolong this however do we want their last hours to be spent, thirsty and hungry?

And back to my original point when you leave the ward and one of these patients has died how do decide if it was a success or a failure on your part?

The Rain

As a gastro medical/surgical ward, my ward sees a lot of alcoholics. Many of these are frequent flyers. Many bloggers from the ambulance service tell you about the trouble drunks give them on a regular basis. So I thought I would give you a little insight into what happens when those drunks actually get admitted to hospital.

Michelle(obviously a pseudoname) has wrecked her body with drink. Her brain barely functions and she often just sits and stares at the wall, saliva streaming out of her mouth and pooling in her lap. She is perfectly mobile and can answer direct questions. Her liver barely filters out the everyday toxins that wouldnt cause a healthly liver any problems. These toxins occasionally accumulate and attack her brain further. She has been a regular on and off the ward for almost a decade. Every time she comes in, we stablise her with a regimin of vitamin supplements and iv fluids and discharge her. The doctors insist their tests show she is mentally fit enough to look after herself, so they release her back to her home which has no electricity, no heating, and no water because the complexities of paying bills is a little beyond her level of comprehension. That night shes found roaming the streets of her town, naked in the pouring rain. Shes brought back into A&E, they send her back to us and the cycle starts again.

Now section three of the mental health act states that any patient who is deemed a danger to themselves or others should be placed into an appropriate mental facility where they can at best be rehabilitated, at worst protected from themselves. However the medical team in their infinite wisdom suggest that this women isnt a danger to herself. Their tests prove it.

On this ward I am learning how truely frustrating this job can be. We are working ourselves to the bone in order to save people who dont want to save themselves. But we still do it, with the same vigor we show patients who havent brought their conditions on themselves.