Catch 22

A patients blood pressure dropping can indicate nearly anything, couple this with raising tachycardia(Increased Pulse Rate) and pyrexia(Raised Temperature) and you probably have a patient suffering sepsis. Until the antibiotics sort out the sepsis(assuming a surgical pathway hasnt been taken) you have to deal with the patients blood pressure. it needs to be raised to a point where the whole body is receiving enough blood regularly. The popular method of doing this is hanging saline regularly as well as another IV fluid called gellofusin. The idea is that at least you are keeping the circulating volume up even if the actual contents is a little diluted when it comes to oxygen bearing red blood cells.

A common result of cardiac incidents, or general poor cardiac function is the collection of fluid in the preferies(Oedema), and usually this fluid makes its way onto the lungs. This is pretty easily resolved with a nice little diuretic we use called Furosemide. This causes any excess fluid in the body to be passed through the kidneys, into the bladder and given the condition of most of my patients straight into their cathater bag.

So what the hell do you do when you have a patient who has a plumeting blood pressure and is overloaded to the point where their lungs are severely comprimised?

The doctors caring for this patient decided to try and maintain a balancing act, putting enough fluid in to keep her blood pressure compatible with life whilst putting enough furosemide in to stop her drowning. Not an easy thing to do and I dont envy them.

IPLU

So tomorrow is the last day of my InterProfessional Learning Unit for this year. Myself and a group of medical students, ot students, pharmacy students and other nursing students have been auditing some bits and bobs on a neonatal unit. Its been fun but I really miss being a real student nurse so I'm glad this is nearly over.

One thing I haev learned from this unit is that neonatal care scares the hell out of me. I'm an adult branch nursing student. Adults and big, smelly and in general foolish. They are far less fragile than neonates(usually). In general if a neonate is sick enough to be admitted to a ward they are probably balancing on a knife edge. Adults get admitted for everything from a social sort out to the sniffles.

I also have a hard time connecting with paedeatrics and neonatal nurses. In my experiences adult nurses bond with the use of dark humour and grim satire. Paeds nurses are all happy and bubbly. Its probably hard to apply dark humour to critically ill babies.

After tomorrow I get to spend a few days in the lake district. to relax, recoup and drink heavily. Then i'm back and spending a few months in my local A&E department. I am really looking forward to this however I suspect my only duties are going to be taking obs. I cant imagine there is a lot in A&E students are allowed to do.

Two Patients

Patient One

• 18 Year Old Male.
• No Medical History, Normally very healthy.
• Very fit and active.
• Presented to A&E with acute abdominal pain.
• Diagnosed with appendicitis with immediate risk put on the next mornings surgical list.
• Patients family are hypochondriacs and overly dramatic panic mongers.
• Patient goes into theatres for a perfectly routine procedure.

Patient Two

• 87 Year Old Male.
• Repeated relapses of cancer over the last 20 years.
• Chronic Obstructive Pulmonary Disease.
• Not very active and in pretty rough shape at the best of times.
• Patient admitted with increasing Shortness of breath due to infection.
• Infection not responding to antibiotics.
• Deterioration indicates that patient meets the criteria for the liverpool care pathway(will be dead within 72 hours).
• Very upbeat, has had a hard life and accepts everything that is happening.
  

I have treated patients similar to both of these although neither of these patients is exactly like any one patient I have treated. Now heres the challenge for any of you poor readers, Tell me what I will find if I go back in three weeks to see these patients. And tell me why I will find what I do.

Sleep

Its 0425.
Every muscle in my body is aching.
I can barely find the energy to sit up in my chair.
My mind has slipped into an energy sparing melancholia.
I should be fast asleep.

But I'm not. I've spent the last five hours staring at my bedroom ceiling, unable to sleep despite the new depths of fatigue I am currently exploring. I've been back in lectures for a while. Thus the lack of posts, I havent had anything of worth to blog about. Given how exhausted I've been when on placement I decided to take some time off working as a bank carer as well. Finally get some time to just be a student. Unfortunately this is how my body always reacts when I go a prolonged period without work. The lecturers arent challenging(for anyone) at the moment, and despite the fact I am still being very active for some reason I just cant seem to function unless I am working myself to the point of sickness.

In the past I have tried everything through medications, herbal remedies and alcohol (not at the same time) to correct this purpose-deprived insomnia but nothing touches it. So I thought I would throw it out to all you guys, what wierd and wonderful tactics/potions/tricks do you guys use to treat insomnia. Anyone who comes up with something that actually works will earn my undying gratitude.

Mythology: Vampires

Most cultures have superstitions involving beings more or less similar to what we call vampires. In this post I intend to offer a possible medical explanation for these creatures. A condition known as Porferia is caused by a malformation of an enzyme in haem. Haem is a crucial element in our blood and allows our red blood cells to bind to oxygen. The condition can easily be fatal without a treatment, a suppliment of artifical haem. Lets break down the "signs" of vampirism.

Drinking Blood
The folklore states that vampires need to drink blood in order to survive. This is technically a solution for porferia suffers, Ingesting large amounts of human blood would provide the required elements to suppliment low haem levels. However most of the ingested blood would be immediately broken down and unusable in the stomach.

Sensitivity to Sunlight
Three types of porphyria are associated with a sensitivity to light, which can be as extreme as sever sunburn at minor exposure. Most sunscreens are totally non-effective.

Complexion
Most legends suggest that vampires are very pale in complexion. Maybe because the legends state they dont get out much during the day? Most people suffering from porpyria are very pale in complexion as a result of barely functioning red blood cells.

Despite all this there are a few bits where the legends dont match up to the medical condition. As far as medical science is aware porphyria suffers cant fly. Also the legends all seem to give vampires a far eastern european accent. Porphyria is one of surprisingly few condtions that dont seem to effect any ethnic group more or less.

This connection has been suggested in the past by many academics one of the better works was a paper writen by a biochemist named David Dolphin in 1985. These suggestions are deeply contravercial as it adds an additional stigma unto suffers of what is in reality a very natural and saddening condition.

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?