I am approaching the end of my course, qualification awaits. All I have to do is pass this final placement. Which given the proficiencies I have to demonstrate shouldnt be a problem. These a proficiencies that frankly any third year student nurse should have been proving for over a year now.
The trouble is I am currently on a very very long easter break from this placement. Eight weeks!. Most people seem to enjoy a bit of time off. I love the odd day doing nothing. However there are no bank shifts going at my hospital due toa combination of closing wards and everyone else being off and wanting work. My personal problem is that when I am left without work for a prolonged period I always seem to find a way to very expertly derail my life. This usually involves a combination of boredom and either over-exercise or over-drinking. Whilst alcohol doesnt cause me to make as big a fool out of myself as it seems to most people. It does trigger a massive personality change in which I become a complete and utter bastard. Fortunately for me I am marrying a girl who knows how to handle this. Generally with strong words or a series of increasingly painful slaps around the back of the head.
I just get sooooo bored when I have no work to do.
Monday, 5 April 2010
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
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.
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.
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.
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.
Friday, 26 February 2010
Making and Appointment
A few months ago I phoned up my GP surgery to make an appointment for my fiancé. The receptionist not for the first time asked me what the appointment was for. Receptionists are not doctors or nurses, and whilst many of them do a very good job deal with the more idiotic elements of the community on a daily basis they have no right or reason to ask why you are making an appointment. Certainly in my surgery the information does not reach the doctor before you see them, they can not suggest you see a nurse or not make the appointment instead, they do nothing with the information. I had a choice, I could explain this to her in a calm and non-confrontational manner or I could take the childish option......
Me: "The patient is a 24 year old female presenting with pyrexia with haemoptysis and epistaxis with intermitted hypertension and tachycardia. No previous relevent medical history or history of recent trauma. Whats your Diagnosis doctor?"
Receptionist: "I'm not a doctor, I'm just a receptionist"
Me: "They train receptionists to diagnose?"
Receptionist: "No I..."
Me: "to triage patient appointments allowing more acutely unwell patients a chance to obtain an appointment?"
Receptionist: "No its first come first ser..."
Me: "Ah so you pass on the relevent information to the doctor so they are prepared for a patient before they arrive?"
Impressively Resilient Receptionist: "No we dont note the information anywhere we arent allowed to write in patient notes or their electronic records...."
Me: "So what times her appointment?"
I dont feel good about the above conversation but I had recenly taken my fill of GP Surgery Receptionists on my community placement who were just asking patients what they were seeing a doctor for out of pure curiousity or "incase the information became useful later". To be fair the last few times I have phoned my GP surgery the receptionists have been very curteous and not asked me for any confidential information, they have simpley done what they are paid to do.
Me: "The patient is a 24 year old female presenting with pyrexia with haemoptysis and epistaxis with intermitted hypertension and tachycardia. No previous relevent medical history or history of recent trauma. Whats your Diagnosis doctor?"
Receptionist: "I'm not a doctor, I'm just a receptionist"
Me: "They train receptionists to diagnose?"
Receptionist: "No I..."
Me: "to triage patient appointments allowing more acutely unwell patients a chance to obtain an appointment?"
Receptionist: "No its first come first ser..."
Me: "Ah so you pass on the relevent information to the doctor so they are prepared for a patient before they arrive?"
Impressively Resilient Receptionist: "No we dont note the information anywhere we arent allowed to write in patient notes or their electronic records...."
Me: "So what times her appointment?"
I dont feel good about the above conversation but I had recenly taken my fill of GP Surgery Receptionists on my community placement who were just asking patients what they were seeing a doctor for out of pure curiousity or "incase the information became useful later". To be fair the last few times I have phoned my GP surgery the receptionists have been very curteous and not asked me for any confidential information, they have simpley done what they are paid to do.
Wednesday, 24 February 2010
Mid-Staffordshire NHS Trust
Many of you have probably already heard about the investigations and subsequent report that has suggested that several hundred more patients than predicted died in the Stafford Hospital emergency department between 2005 and 2008. The report also indicates that staff were uncaring and more focused on saving money than treating patients.
Whilst I do not in any way condone the treatment of these patients I dont blame the nurses or doctors at this trust. They became EXACTLY what the NHS is training us to be. If a patient comes in to A&E we have a four hour breach target. So if the patient is still present on the department four hours after first being seen by a triage nurse the department recieves a fine to its next budget. You have four hours to fully investigate a patient .It can take longer to get blood test results back or find a radiographer to take an xray for you. Add to this the fact you see a lot of the same patients every week who "cry wolf" if you have to save time and money for your department(money that may well be used to pay you) the temptation may be to discharge the same old patients without a complete investigation(I promise you that will be the time they are actually ill).
You then have cost limits on treatment, if a patient needs a dressing we are told to use the cheapest dressings available that are not likely to get the trust or practitioner sued for malpractice. For example if you have a deep pre-tibial lasceration(a deep cut to your shin) we will have to chose a non adhesive layer to prevent the top layer of gauze sticking to the wound bed, realistically there are three options -
1. Release - A sort of thin gauze covered in some kind of oil to prevent it sticking. The oily layer dries within a few hours and the release then becomes stuck to the wound bed, to remove you have to soak the dressing in saline and if you are very very lucky you wont reopen the wound. Very Cheap.
2. Atraumen - A greasy mesh that stays non-adhesive for about three days(at which point the wound should be assessed anyway), doesnt do a bad job. Moderately Expensive.
3. Mepitel - A silicone based mesh that I have never known to dry out while covering a wound, can be used for upto about 18 depending on trust policy. Primarily designed for burns but still incredibly effective as a general non-adhesive, can also be used to draw a wound together in the absence of steri-strips. Does an unparalleled job. Fairly Expensive.
In my trust we are told never to use mepitel and we can only use atraumen if a senior doctor has signed off on it. There is a similar system for anti-emetics(anti sickness drugs) we give cyclizine because its cheap, although it does make patients very light headed and dizzy. I would personally refuse anything except donperidone which does the same job but without the unpleasant and very common side effects.
Fortunately the hospital I work in completely ignores the targets set by people so far up the chain of command they dont even know what a hospital looks like. If we feel a patient is less likely to develop an infection because we have used mepitel we use mepitel, if a patient is clearly distressed by their nausea we will not give them cyclizine, knowing that the secondary effects of cyclizine will distress them further. And I can honestly say I have never discharged a patient without ensuring they have some help in place. Even if I dont believe what they say is wrong with them and they came to us instead of their GP I will phone their gp and make an appointment for them knowing I havent just left them out on their own.
What has happened in Staffordshire is tragic but it is the result of government and NHS target setting and the threat of penalties to any trusts that dont meet these unrealistic targets generated by people who either have no clinical experience or had it so long ago operating theaters floors were still covered in sawdust. The new chief executive of this trust has already proven a massive improvement in care since hiring close to 200 extra nurses.
As a side note if I were to become ill this is now the trust I would want to go to. Given the scrutiny this trust is under it will probably be demonstrating exceptional standards of care for some time, whereas many other hospitals which receive good marks have probably grown complacent.
Whilst I do not in any way condone the treatment of these patients I dont blame the nurses or doctors at this trust. They became EXACTLY what the NHS is training us to be. If a patient comes in to A&E we have a four hour breach target. So if the patient is still present on the department four hours after first being seen by a triage nurse the department recieves a fine to its next budget. You have four hours to fully investigate a patient .It can take longer to get blood test results back or find a radiographer to take an xray for you. Add to this the fact you see a lot of the same patients every week who "cry wolf" if you have to save time and money for your department(money that may well be used to pay you) the temptation may be to discharge the same old patients without a complete investigation(I promise you that will be the time they are actually ill).
You then have cost limits on treatment, if a patient needs a dressing we are told to use the cheapest dressings available that are not likely to get the trust or practitioner sued for malpractice. For example if you have a deep pre-tibial lasceration(a deep cut to your shin) we will have to chose a non adhesive layer to prevent the top layer of gauze sticking to the wound bed, realistically there are three options -
1. Release - A sort of thin gauze covered in some kind of oil to prevent it sticking. The oily layer dries within a few hours and the release then becomes stuck to the wound bed, to remove you have to soak the dressing in saline and if you are very very lucky you wont reopen the wound. Very Cheap.
2. Atraumen - A greasy mesh that stays non-adhesive for about three days(at which point the wound should be assessed anyway), doesnt do a bad job. Moderately Expensive.
3. Mepitel - A silicone based mesh that I have never known to dry out while covering a wound, can be used for upto about 18 depending on trust policy. Primarily designed for burns but still incredibly effective as a general non-adhesive, can also be used to draw a wound together in the absence of steri-strips. Does an unparalleled job. Fairly Expensive.
In my trust we are told never to use mepitel and we can only use atraumen if a senior doctor has signed off on it. There is a similar system for anti-emetics(anti sickness drugs) we give cyclizine because its cheap, although it does make patients very light headed and dizzy. I would personally refuse anything except donperidone which does the same job but without the unpleasant and very common side effects.
Fortunately the hospital I work in completely ignores the targets set by people so far up the chain of command they dont even know what a hospital looks like. If we feel a patient is less likely to develop an infection because we have used mepitel we use mepitel, if a patient is clearly distressed by their nausea we will not give them cyclizine, knowing that the secondary effects of cyclizine will distress them further. And I can honestly say I have never discharged a patient without ensuring they have some help in place. Even if I dont believe what they say is wrong with them and they came to us instead of their GP I will phone their gp and make an appointment for them knowing I havent just left them out on their own.
What has happened in Staffordshire is tragic but it is the result of government and NHS target setting and the threat of penalties to any trusts that dont meet these unrealistic targets generated by people who either have no clinical experience or had it so long ago operating theaters floors were still covered in sawdust. The new chief executive of this trust has already proven a massive improvement in care since hiring close to 200 extra nurses.
As a side note if I were to become ill this is now the trust I would want to go to. Given the scrutiny this trust is under it will probably be demonstrating exceptional standards of care for some time, whereas many other hospitals which receive good marks have probably grown complacent.
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