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?

Back

I have returned. My abscence over the last month has been down to two things. Firstly I finished my third placement and thus didnt have a huge amount to talk about and secondly I spent a good couple of weeks over the christmas period in a state that some refer to as being 'bladdered'. But now I have returned and though I am not back on placement I am back to working (to earn money so I can afford to stay on my course).

I'll start with an old familiar topic just to ease my return. HIV and Population control.

Everyone knows what Human Immunodeficiency Virus is, admittedly the general populous have a very misguided interpretation of what it is and who it effects. The potential target group for this virus is EVERYBODY! not just homosexuals and drug addicts. Now we've cleared that little misunderstanding up lets move on.

There is a very similar virus that effects monkeys, Its called Simean Immunodifficiency Virus(SIV). Studies have suggested that the earliest outbreaks of this virus occured in africa. This isnt terribly shocking considering the earliest species of simean have been found in africa. Now, several thousand years after the first suggested outbreaks of this virus there are many native monkeys in africa which show absolutely zero uptake on this virus. They are either immune or resistant to the point where you might as well call it immunity. However if you expose for example an asian monkey to SIV they will almost certainly contract it with ease.

This leads us to beleive that there were monkies in africa which were both vulnerable and immune to SIV, the virus killed off all of the vulnerable monkies leaving behind just those which were immune, this immunity was passed on from generation to generation and from that point SIV was almost removed from africa. Should this also be the case for humans and there are those out there with an immunity to HIV(and there is no evidence that this is the case) then HIV could just be another one of mother natures population limiters.

In bacteria there are various principles of growth. Give a bacterium x amount of nutrients in a petris dish and expose it to the perfect amount of heat to promote growth and at first they spread at an incredible rate....then they slow as food becomes limited and excreted toxins start to build up, but at this point they are still in a state of population growth. They then stop, an equal amount of bacteria are dying due to lack of nutrition or exposure to toxins than are being created through further growth. And finally the culture starts to die, there are too little nutrients available and far too much toxic exposure. They have grown to their deaths.

Mankind is doing something similar, although we are still in a state of exponential growth. But the cause of all this 'global warming concern' is that we are facing the inevitable. In this history of this planet we have had an insane number of ice ages, then the ice melts(entirely) so even the polar caps are water, leaving only the highest of land above water. This has never really been a problem before because what few humans there were on the planet could fit into the visible land masses. Unfortunately now with 6,700,000,000 people on this planet we dont have any space to allow the entire species to survive a perfectly normal interglacial period. This period of defrosting is happening not because of us or our 'carbon footprint' but becuase it is meant to happen as it has always happened. Admittedly our effect on the environment may have expediated the defrosting but not by a huge amount.

There we go, Rant over. Have you all missed me?

Drinking it In

Every shift I turn up at work half an hour early. I grab a cup of coffee and sit in plain view of the ward. Its the only time you get a chance to do this. Once you start working you have the blinkers on and you cant really get a feel for whats happening on the rest of the ward. So i sit, and I watch, I watch where the carers are focusing the most attention (even if they dont realise it themselves) I assess which patients will need two for assistance with a wash and which will need one. I note the noisey dementia patient who was probably screaming all night and make sure that is the last bay I go to so the others in there can get some rest once I have moved her to a cubicle.

I sit there and let it wash over me. And I have to say, its an incredible feeling. I am definitely an acute ward nurse. The ward is my home, and whilst I have the highest respect for scrub nurses I could never be one, I dont have it in me, and as far as community goes? I dont have the stamina to see hundreds of patients who all need wound dressings every week. I love wound dressing but not in that quantity.

On equal note I dont think I could be a surgical nurse for all of my career. This is more down to preference I am a medically minded person. I love the intricies of renal failure and the challenges of COPD.

I am an acute medical ward nurse.

Laughter

Yesterday we saw one the patients the entire ward had grown very fond of die. Thankfully it was very quick and painless. The mood of every member of staff on duty, from the sisters to the domestics dropped. Later than shift we had a quiet moment, someone (one of the class clowns) cracked a barely amusing, entirely inoffensive joke. The resulting laughter from everyone lasted several minutes and washed away the low moods. It was just the catalyst we needed to release it all.

Unfortunately in this job you dont really have time to stop and think about the bad things. A patient you cared about dies, you have to keep going because if you dont other patients will. The job doesnt stop to let you heal. In some ways I am grateful for that because if I stopped to think about every patient on any one ward who died I would probably end up killing myself.

The Job doesnt stop, so we cant either.

Three Patients

Well i'm back to fighting strength, which is good. I'm also doing really well on this placement....so I'm told. I have to admit that I am going to miss it. My time with them finishes on the 12th but I have four shifts to make up so it might be a little later than that. Its been a good placement and I've regained all the confidence I lost on my last placement. I am also enjoying being a student nurse on placement with no assignments hanging over my head.

Yesterday we had a patient who went for a liver biopsy, when he came back he hadnt had the biopsy and had an acitic drain inserted(a tube inserted to drain large collections of fluid). The bag this was draining into was only 500mls. after the first two hours of emptying this bag every half and hour I decided to attach a 1.5 litre bag. To my amazement the fluid was draining even faster, it appears as long as there is space it will drain incredibly fast. This fluid loss obviously had to be compensated for so we were hanging bags of FFP(Frozen Fresh Plasma) and towards the end of my shift we had to clamp off the drain and hang bags of saline. All in all the man lost almost 10kg in a few hours. This cant be healthy! but he said he felt great and the doctors didnt seem concerned.

We have another patient who was doing so well, he's been with us for months and was medically fit for discharge until he contracted the D+V the ward was closed with, he finally got over that and seems to be in decline again. His blood pressure is in his boots, he's tachycardic, and very pyrexial. All of which leads me to believe he's septic despite the high doses of antibiotics he's on. This is an example of a patient you cant help but get attached to and at 90 years old I am not sure he'll see discharge this time.

Patient number three had the entire staff of my ward in tears yesterday(myself included). He is dying, he is very much at peace with his fate, he has at best a few weeks left and just wants to die in hospital so his family dont walk into his room one morning and find him dead. He had written a poem to his wife that is by far the most beautiful thing I have ever read.

So theres my three patients, the healthy, the declining and the dying.

Highs and Lows

Yesterday I got to run my own bay, with six acutely ill patients. There was no one watching my back, I had my own healthcare assistant and I was responsible for getting one of the qualified nurses to administer drugs when I asked them. If I didnt ask the patient didnt get. It was huge for me, I didnt screw up, it all came off without a hitch and was a massive step for my training.

Unfortauntely today I am feeling rough, very rough. My ward is still infected with norovirus and I was hoping the fact I had only just gotten over this virus meant I had a greater resistance. Unfortunately Virii have a habit of mutating so the immune system cant recognise it and you just end up getting reinfected.

Also given I have just reread this post It appears I'm not thinking too clearly either.

The Songs We Sing

I have mentioned before that there are certain songs that would lend themselves to the soundtrack of ward life. I thought I'd list a few of these based on the activities involved -

Performing CPR - Triumph - Fight the Good Fight

Having 1000 demands made on you at once - David Grey - Please Forgive Me

Trying to convince a dementia patient we arent stealing their blood Fountains of Wayne - Hey Julie

Trying to keep a mobile dementia patient from leaving the ward unnoticed
- Thin Lizzy - Jailbreak

Trying to get a doctor to canulate a patient at 0300 - Manowar -Fight until we die

Starting a Shift on a crisp, cold afternoon - Butthole Surfers - Dracula from Houston

A Moment of complete warm fuzzy teamwork - Iron Maiden - Children of the Damned

The end of a shift - Show me the way to go home