Saturday, 19 May 2007
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.
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.
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.
Friday, 27 April 2007
Getting Home
Why is it that patients become unable to get home once discharged. They automatically assume the God-given right to free transport home; either a paid taxi, or worse a frontline 999 ambulance. I can have a certain understanding of the little old chap or lady being taken back to their residential home, but grown adults of 18 plus.
Oh but I pay taxes they sqwark, well no shit, so do I. Find your own way home, you should'nt have been here in the first place.
The drunks are the best; what would you have done if you hadn't fallen over and twatted yourself on the head? you ask. Oh, I would have had a taxi or pulled. Right then dickhead, go and find one now.
Gomer.
Oh but I pay taxes they sqwark, well no shit, so do I. Find your own way home, you should'nt have been here in the first place.
The drunks are the best; what would you have done if you hadn't fallen over and twatted yourself on the head? you ask. Oh, I would have had a taxi or pulled. Right then dickhead, go and find one now.
Gomer.
Monday, 19 March 2007
Take Away?!?
Had a 86 year old post arrest. Flat and not particularly healthy. Shocked a couple of times by the paramedics and once by myself. A rather pro-active medical registrar suggested thrombylisis which was duly given, however the proglonged event lead to a termination of actively treating her.
Then the problems arose. The first two members of the family refused to believe she was going to die, and would not allow extubation til their sister arrived. Fine we said expecting them to be local. But hey no, they were coming from Wales. Didn't they know about breaches. Needless to say I had to try and keep this lady alive til these family members arrived. Cue ventilator and a bit of luck.
The family eventually arrived, and were with Mum. I extubated and 5 minutes later she died, with her family present. It gave the family some comfort.
As I was leaving one of the daughters came up to me and said that they wanted to take mum 'home with them'. Small problem she was dead.
Unfortunately not I said, as she was now the property of the coroner and it would be theft, also unethical and unhygenic. The transportation issue would have been fun too. A longboard and roof rack were mentioned.
Relatives are bizarre.
Then the problems arose. The first two members of the family refused to believe she was going to die, and would not allow extubation til their sister arrived. Fine we said expecting them to be local. But hey no, they were coming from Wales. Didn't they know about breaches. Needless to say I had to try and keep this lady alive til these family members arrived. Cue ventilator and a bit of luck.
The family eventually arrived, and were with Mum. I extubated and 5 minutes later she died, with her family present. It gave the family some comfort.
As I was leaving one of the daughters came up to me and said that they wanted to take mum 'home with them'. Small problem she was dead.
Unfortunately not I said, as she was now the property of the coroner and it would be theft, also unethical and unhygenic. The transportation issue would have been fun too. A longboard and roof rack were mentioned.
Relatives are bizarre.
Sunday, 4 March 2007
The wheat from the chaff
The Trust is desperately trying to reach the Government target of 98% of patients are dealt with within 4 hours. |For the most part we have been doing well; that was until Friday. Two breaches by lunch and more than twenty by the end of the day.
I came across a senior sister crying as she was doing her best. Is it a good working environment when people, granted even the least clinically credible sister (although a decent person) is reduced to tears by virtue of the atmosphere. Maybe they are trying to cull those who cannot control the department, but when there are no beds available breaches will occur. And when there are sick patients, which they have been and there are shortfalls in nursing staffing levels then this will become the norm for breaches to occur.
On top of that we have been awarded a 1.5% pay rise this year by Patricia (No clue) Hewitt, lee than the rate of inflation. What an insult to the hard work by nurses up and down the country! Get a grip, the Medical training is ballsed up, the waiting lists are manipulated with minimum waiting times, MRSA is rife and nurses are becoming scapegoats, the NHS needs to be revolutionised by those who understand it; the NHS staff, not idiots in the DofH.
I came across a senior sister crying as she was doing her best. Is it a good working environment when people, granted even the least clinically credible sister (although a decent person) is reduced to tears by virtue of the atmosphere. Maybe they are trying to cull those who cannot control the department, but when there are no beds available breaches will occur. And when there are sick patients, which they have been and there are shortfalls in nursing staffing levels then this will become the norm for breaches to occur.
On top of that we have been awarded a 1.5% pay rise this year by Patricia (No clue) Hewitt, lee than the rate of inflation. What an insult to the hard work by nurses up and down the country! Get a grip, the Medical training is ballsed up, the waiting lists are manipulated with minimum waiting times, MRSA is rife and nurses are becoming scapegoats, the NHS needs to be revolutionised by those who understand it; the NHS staff, not idiots in the DofH.
Friday, 2 March 2007
Trauma Continued
This is from the respected Trauma.org website on the management of severe Head Injuries.
(Us ED folk DO know what we are talking about) (most of the time).
Assessment of brain injury hinges on evaluation of the Glasgow Coma Score (GCS) and examination of the pupils. Traditionally a GCS of below 9 is considered to reflect severe brain injury. However with improvements in prehospital care and greater knowledge of brain injury, patients are arriving in emergency departments earlier and their brain injury may still be evolving. Therefore the following measures should be considered and porbably instituted in all patients with coma scores of 12 or below.
Management
The specific goals in the acute management of severe traumatic brain injury are:
1. Protect the airway & oxygenate
2. Ventilate to normocapnia
3. Correct hypovolaemia and hypotension
4. CT Scan when appropriate
5. Neurosurgery if indicated
6. Intensive Care for further monitoring and management
Hypoxia and hypotension are the greatest threat to functional outcome in brain injury. Early acute control of the above three parameters may have more impact than all other measures subsequently employed. Progressive neuronal loss occurs from the time of injury, not the time of arrival in hospital. Rapid sequence intubation should be used where available to secure the airway and maximally oxygenate the patient. Hypovolaemia and hypotension must be corrected early and take priority over other interventions for the brain injury. Other injuries causing haemorrhage must be addressed first (or simultaneously) so that an adequate cerebral perfusion pressure is maintained. Patients should be kept sedated to prevent coughing or valsalva maneuvers from fighting the ventilator, as these increase intracranial pressure.
(Us ED folk DO know what we are talking about) (most of the time).
Assessment of brain injury hinges on evaluation of the Glasgow Coma Score (GCS) and examination of the pupils. Traditionally a GCS of below 9 is considered to reflect severe brain injury. However with improvements in prehospital care and greater knowledge of brain injury, patients are arriving in emergency departments earlier and their brain injury may still be evolving. Therefore the following measures should be considered and porbably instituted in all patients with coma scores of 12 or below.
Management
The specific goals in the acute management of severe traumatic brain injury are:
1. Protect the airway & oxygenate
2. Ventilate to normocapnia
3. Correct hypovolaemia and hypotension
4. CT Scan when appropriate
5. Neurosurgery if indicated
6. Intensive Care for further monitoring and management
Hypoxia and hypotension are the greatest threat to functional outcome in brain injury. Early acute control of the above three parameters may have more impact than all other measures subsequently employed. Progressive neuronal loss occurs from the time of injury, not the time of arrival in hospital. Rapid sequence intubation should be used where available to secure the airway and maximally oxygenate the patient. Hypovolaemia and hypotension must be corrected early and take priority over other interventions for the brain injury. Other injuries causing haemorrhage must be addressed first (or simultaneously) so that an adequate cerebral perfusion pressure is maintained. Patients should be kept sedated to prevent coughing or valsalva maneuvers from fighting the ventilator, as these increase intracranial pressure.
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