An unglorified death

Emergencies and death are part and parcel of nursing, neither come at good times and often come together. And 7.30am in the morning, on a shift where in their eternal wisdom, they have decided to have no senior nurses over the whole ward, is not a good time. And as you run to the sound of the emergency buzzer, you know 9 out of 10 times, it will be nothing, but not this time.

Not many people come back from arrests, moreso with the type of acute patients on our ward, and though the patient has the appearance of being long dead, no action equates to no chance, so the whole procedure carries on, CPR, medical team called. Under instructions from the medical team, we continue CPR. He has Rigor, one nurse states. “Rigor?” comes the confused reply. “Rigor Mortis”, the body has already started to become stiff is the reply. “Okay, stop and reevaluate is the response”, the result of the reevaluation is to continue as before, and before we know it, 30 minutes has passed without any further response. Then they finally call it.

There’s no cooling down period, or consultation, just straight onto handover and then onto drug round. There is time for tears, but only if you are working at the same time. And it’s almost gratifying to be pulled aside and criticised that patients drinks were not in front of them, although they were when I gave out the morning medication. We are back amongst the living again.

The Rollercoaster of Blame

Imagine a world where you rarely take a lunch break, always work late and never get paid for it (and when trying to do so, you are reminded that you are committing fraudulent activity), where you can’t take your full entitlement of holidays because of staff shortages which then get taken away from you without being paid for it either. Imagine this world where everyone wants to blame you for something, whether it be the ward manager, other nurses, doctors, relatives, and that nothing you can do makes any bit of difference, where your patient ratio is 1 to 12, where most things handed over are not done, because the workload is completely impossible.

But this world is not imaginery, it is real, and it’s horrific. You wouldn’t put up with it in any other walk of your life or in any other job, but we do because it is the only framework we have to work to. Where every day you can’t possibly think it will get any worse, but surely, inevitably it does. It’s like some type of anti-groundhog day, but without either the charm of Bill Murray or the down to earth attractiveness of Andie McDowell.

And no matter how many big posters you are producing of stick men climbing up ladders to sit atop lego blocks, or how many glossy brochures you produce (theres no “I” in team), the rollercoaster which once was an exciting and thrilling experience is now full of screamers desperately trying to get off.

Marjorie

I am on an elderly rehabilitation ward. The standard of care is not very good to say the least, there is a lot of infighting and personality clashes between the nursing staff, which lead to incidents like leaving patients on commodes for over 45 minutes, because as “it’s not their patient”, they won’t give them care. There is an overblown staff meeting every day after lunch where patients are sitting in a large residential area. There is a blind patient who won’t keep still and keeps getting up, wanting to go back to his room. No one will help him back to his room as they are all in this meeting and because he won’t wait he ends up falling into the television set in full view of all the ward staff who are sitting in the office.

On this ward, I meet an elderly patient with advanced dementia, you’d describer her as “pleasantly confused”. However, with patients with dementia, long term memory is much sharper than short term memory and she is able to recall facts about her past – she used to own a greyhound called Derry Boy Dancer who competed in the greyhound derby at Wimbledon. When I came in one day she seemed a little less happy than normal and a lot more drowsy and not really communicating. I couldn’t find out what was wrong and she wanted to be left alone so didn’t push it any further.

The next day, whilst the patients typically sit around after lunch for 2 hours, she is sitting at the table, and to me appears still drowsy and not communicating that well. It’s my first placement, and I have read through over ten books about the care of the elderly, but unfortunately books are not the real world, and I don’t have any nursing experience at this stage, so when I go back to see her an hour later, something is evidently wrong, she coughs, she looks clammy and a river of snot flies down her face. I alert the nursing staff who take appropriate action; she’s suffered a major stroke, she hangs on for a long one and a half weeks, but never regains consciousness and dies. The comment from the ward manager that she is probably better off dead as she had no relatives visiting her and she was “confused”.

Should I have noticed something was wrong? Probably. Should other, more experienced staff members checked on her condition in the two hour space she was left unattended at the table. Definitely. Do I still feel guilty that I could have made a difference if I had noticed things earlier. Yes, without a question.

It’s two years later. I’m in accident and emergency, and I’m in resuscitation. There’s a blue light call coming in, turns out to be a 39 year old male with SOB and feeling acutely unwell and presenting as cold and clammy, recently returned from a holiday abroad, had previously gone to GP surgery with feeling unwell and breathless, the receptionist at his surgery sent him home telling him not to waste their time. He felt worse the next day, went back to the surgery, but never made it and collapsed in the street. It’s a bog standard presenting PE, but as the team take the bloods, he says his first and last words of the day – “I’m going to die now” – his eyes roll back into his head and instantaneously dies, I perform chest compressions, but they call it five minutes later. He left behind a wife and two young children, the childrens books in his bag tell me this long before the call needs to be made.

Priorities of care

It’s not an untypical early morning shift on an acute medical ward. I have a woman patient with MS with a chest infection, who, unable to move in bed has just vomited down herself and is at risk of aspiration, I have a patient who has fallen over in the toilet, which may be a case of unbalancing, but he came in suspected stroke/PE so needs checking out; in the next room is a dying patient on a syringe driver with constantly changing BMs, with an anxious family in situ.

Whilst trying to deal with the vomiting patient, a nursing auxiliary rushes over to me, saying a patient is having chest pains. I leave what I am doing and go to assess the patient. All observations are stable, there is no shortness of breath, patients colour is good, no signs of sweating or clamminess, patient is actually presenting with muscular pain but does not seem to be in particular distress, though has anxiety about his discharge which tends to manifest in physical symptoms. He also has no impending sense of doom. He does have a history of triple A’s and is DNAR. I give analgesia as prescribed and tell the patient I will be back in five minutes to see how he is, and go back to the vomiting patient, while informing two nursing auxiliaries about the patient who has fallen in the bathroom. I suction the vomiting patient and assess her breathing, chest sounds; she also seems to be forming a scaly rash around her neck and face. After she is settled, I do a set of observations on the patient who has fallen over in the toilet, he says he overreached and his observations were stable. I then go back to check on the patient I got told about by the nursing auxiliary, he seems much more settled and not complaining of pain.

About five minutes later, the ward sister comes over to me and tells me to do an ECG on the patient the nursing auxiliary told me about, apparently the nursing auxiliary had gone to the ward sister telling her that I had ignored the patient with chest pain, which was not the case. Doctors were called, the ECG returns a normal reading, and no nursing interventions are necessary. At the end of the shift, ward sister took me into the sisters office and said she was concerned about the incident regarding the patient with chest pain, I told her that I was dealing with several situations at once and did explain that I had assessed the patient, she told me that I should have made that patient a priority and acted quicker in getting an ECG done, putting the patient on oxygen and alerting the on-call doctors. She said I could have asked for help from other members of the nursing team, but not unusually we were short of staff and there was no-one to help at the time. I accepted her comments as an experienced nurse and made a mental note to incorporate them into any future practice.

About a week later, I am at home and get a phone call from the ward manager telling me she wants to speak to me about “several issues”, but will not tell me what they are about, but wants to see me before I start my next shift, so we agree to meet an hour before my shift starts, however, on arrival to the ward, she is busy so unable to see me until three hours into my shift, which leaves me with an air of apprehension and uncertainty.

When she speaks to me, she says she is concerned about a report she has heard (which is the incident described above) and that I wasn’t prioritising nursing care effectively. I explained to her about the several situations I was dealing with at the time, she told me she was unaware of this information but told me I could always ask for help, however another comment that had been made was that there had been “inappropriate calling for help”, but that was not expanded upon. To be able to call someone for help, you have to have confidence that person will be able to assist you, how can you ask someone for help if someone says you are calling inappropriately, it reduces your confidence and makes you doubt your ability.

On the afternoon shift, there was me and one other trained staff on site with no nursing auxiliaries, no doctor support, with a patient with heart failure. Amongst all this, a new patient came in with Hepatitis A and went in a bay with 3 other males. Two side rooms were occupied, and I was concerned about infection control. I called medical bleep, to which I got the reply “I’m not infection control, look on the internet”. So I try wading through the internet, but the infection control manual is over 200 pages long, and there is nothing specific about Hepatitis A that I can find – and as I am looking, relatives are coming to the nursing station requesting assistance – so in the end, had to walk back to Teal to get advice from the sister there, the reply was that the patient could stay in the bedded space. Okay, it’s a decision I could have made for myself, but if I had made the wrong decision and had spread infection throughout the ward, the consequences would have been far worse. Medical bleep holders tend to be experienced nurses, who more than likely would know the answer to my question, so what was the need to give me short shrift, it reduces the likelihood of asking for help on the next occasion and is demoralising.

Brickbats and boquets

But it’s not all brickbats. There are some bouquets. It’s my second day at work, my supernumery status seems to have disappeared, and I am caring for a team on my own.  A patient has been taking a long time in the toilet, old people can tend to do that, but the patient is not that well and he’s locked the door which concerns me. The last time that happened was in accident and emergency where my intervention found an unconscious patient who was revived. I have to unlock the door with a 5p piece, the sight is not encouraging, the patient has collapsed and has pulled his cannula out, there is a large pool of blood on the floor, and the walls are also splattered with his blood, his mouth is wide open and he looks dead, but on assessment there are signs of breathing. The patients family are gathered around by the bay entrance, so I emergency alarm, get the patient back to his bed with assistance. Someone has called the MET, and they attempt to resuscitate the patient, but I alert them that he is DNAR, so they take some bloods. Patient remains acutely unwell, but begins to recover over the next couple of days. Unfortunately, after about a week, the patient climbs over his bed rails, falls on the floor and loses consciousness and this time does not recover. However, in the first place I was able to act and to get medical attention quickly and was able to act appropriately in an emergency situation.

Then another patient who I knew very well, who had a long and complicated history since admission, with failed NG tubes, aspiration, cardiac problems and history of PE. He had been improving and had been looking forward to discharge. I was doing a drug round and popped into his bay, although he was clinically stable, there was something not quite right about him. I knew the patient well, he was a very non-complaining type of patient with passive relatives and as such sometimes got overlooked. He complained of not feeling right in himself, but being the way he was, he wouldn’t have called out for help. Within the next few minutes, his breathing started to get ragged, his sats dropped, the MET came and were able to treat a potential PE that may have been fatal if not spotted. Okay, some aspects of this may have been luck, that I was passing when the patient began to feel unwell, but it also shows a good understanding of the patient, and how aware you need to be about changing conditions. The patient made a full recovery and was discharged home.