Saturday, 5 May 2007

Dead dead dead

Patient from yesterday; died.

Ambulance service brought in a poorly patient. Refused conveyance from the first crew but later called them back. Brought in. Died. I saw the paramedic who went to him initially. I like this guy, he is compassionate, caring, intelligent and gives a shit. He is so cut up about this man who died, but he DECLINED to go to hospital. I tried to console this paramedic but he thinks he did wrong. He did NOTHING wrong.

Patients. The ones who are not sick want to go to hospital, the ones who are sick want to stay at home. Only God knows the time for our exit from this passage we call life.

Friday, 4 May 2007

Goal Directed Therapy: An Urban Myth?

Goal directed therapy for sepsis. An ideal or an unachievable.

Middle aged man, recent urological surgery came to ED with confusion, hypotension and tachycardia. ABG showed a profound metabolic acidosis and WCC of 30. CRP also rather high at 340. Suggested aggressive intervention ie fluids, inotropes +/- vasopressors, central line and other intensive monitoring, such as a PA line. These were not carried out. A newly qualified, but savvy and competent staff nurse was the nurse dealing and was pushing tis but the drs were not going down this route.

The patiet was transferred down to CT. Next thing is the crash bleep announcing an arrest in the donut of death commonly known as CT. The man had crashed, purple plus major style. EMD arrest; chaos et al (except from my newly qualified colleague who was ace), widespread fluid from the man's stomach exacerbated the intubation, but control was achieved. EMD went to aystole and back to EMD. CPR continued and somewhat later an output was gained. Patient CT'd and then the drs argue about the deposition of the patient. For fucks sake, this is a 56 year old, this man needs ITU. he will probably die but he needs the oppotunity to attempt to live. ITU were not convinced, but common sense prevailed and we transferred the man to ITU. I don't hold out too much hope.

My main issue is that as a nurse who is relatively senior and experienced in emergency and critical care I feel so frustrated by the shackles that nursing entails when we have junior drs who have little experience of dealing with such ill patients. They don't take advice fom nurses and this grates me because I see patient care suffering. Goal directed therapy for whatever presentation sepsis, shock et al should be ALL our goals, but I fear that its not going to happen.