Before I started my nurse training, I didn't have any real experience of hospitals. I'd seen my granddad in one plenty of times, and I'd worked a domestic in a nursing home, but that was about it. But hey, I'd watched Holby City for years - what more experience did I need? *grin*
My first placement went really well. I seemed to just soak up skills and experience. By the end of the first weeks I was giving bed baths, changing dressings, writing in care plans - the works. I thought I was the business.
On my last day, I was sent off to do the obs round. I got to one man who needed a lying + standing blood pressure. I didn't really know why (of course I didn't really know anything except how to attach the cuff and spot if the result was abnormal!), but I started doing it anyway. Loads of patients on this ward had to have them done, I still don't understand why and I doubt the staff there did either. Anyway, the lying part was fine, but then I tried to get him out of bed to stand him up, and there was just no way that was happening.
I'd looked after him loads of times before, and so I knew he could stand up easily by himself. In my naivité, I asked one of the nurses to help me stand him up. She saw at twenty paces that that wasn't going to happen.
I know now that the man had septicaemia. In fact, he'd become very ill indeed. Throughout the rest of the shift, me and the nurse did various things to him - checked his obs, did an ECG, tried to listen to his heart with a stethoscope to see if there was an apex-radial deficit (surprisingly I did know what this was all about, having happened to read about it in a book a couple of days before. I've never had to use it ever again and I doubt I ever will!). Doctors came and went, taking blood tests. He had a chest x-ray. Towards the end of the shift, he looked quite ill, he was having rigors, was photophobic and had a stiff neck.
I don't know what happened to him, but I'll bet any money you like he died at some point over the next 2-3 days. I didn't realise at the time the seriousness of what was going on. I don't think the nurses did either, or at least they didn't show it. The very junior doctor (he'd been out of med school about 3 months) stayed around for the diagnostic challenge, but having satisfied himself that the patient was indeed ill, he buggered off, and nobody else saw him for the rest of the shift.
I know now that this is a classic scenario, occuring on wards up and down the country every day. Patients who show clear signs of deterioration are ignored, or inadequately treated. They deteriorate to the point where it is so obvious that they are ill that they are sent to intensive care, or they have a cardiac arrest. Either way they die - in ICU it's slowly and painfully, if they arrest it's quickly with someone bouncing up and down on their chest. Neither is particularly pleasant, and both can often be avoided. Report after report from the National Patient Safety Agency and the Department of Health shows this happening, NICE issues guidelines to prevent it, but still it goes on.
Thinking back, I'm horrified. I think it was the realisation, 2 or 3 months later, of what I'd seen happen with this man, that prompted my interest in critical care. It's not all about big dramatic emergencies (cool as they seem to a beginner, you tire of them after a while), the best care is often about little things done at the right time. This applies every bit as much to monitoring patients as it does to keeping them well-fed. Sadly, in nursing, neither seems to happen very well.
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3 comments:
Hi Northern Nurse. I am glad that I am not the only person who gets faced with the problem of the patients who deteriorate and have little in the way of back up. It is a sad reality of what happens when things go ary.
Re: Lying and standing BP. Usually, unless there is a considered risk of Postural Hypotension (sudden drop in BP when patient goes from lying to standing) of say a drop of 10mmHg+, then usually it is not ordered. I am puzzled why you were asked to do this if the patient was not easilly moved (unless you were being fobbed off with the difficult patient). I have had to do a lying and "sat up in bed" BP once or twice when immobile patients have had difficulty with sudden light-headedness while sitting up.
I know about postural hypotension, what I was referring to is the fact that the doctors asked for L+S BP in a huge proportion of the patients, hardly any of whom ever compained of lightheadedness on standing. We also did it 3 days running for every patient. I'm completely lost to understand why!
Anyway, this patient was normally completely mobile, but had become bedbound due to his deterioration, which nobody had noticed. I'd like to think that nowadays I would spot signs of deterioration early and get something done ASAP, before it ever got to this state. The hospital concerned actually has a really good crit care outreach service, but it relies on somebody calling them.
As a novice nurse, I didn't really recognise what was going on until the end of the shift, and the full realisation didn't hit me til 2-3 months later. I'm not sure at that stage in my training I could have done any better, but the qualified nurses and doctors should have done. It's not necessarily their fault, it just demonstrates the poor attention which is paid to this area of practise. I sometimes think that ward nurses see nursing as all about dishing out meds and keeping everyone clean, with other things thrown in if there's time. Of course these two things are important, but I value keeping my patients alive slightly higher than either of them. I think I'm in the minority. Just look at what happens when the crash team turn up on a ward - everyone vanishes into the sluice!
Hmmm...it seems even odder put like that. At an educated guess, maybe it just got subsumed into being a Nursing ritual. I suspect that the original logic for L&S BP got lost in the mist of time.
As for looking back: I can identify with that. Trouble I found as a student is having your hands tied so much when it comes to paperwork. As for the area of practice, sometimes it is being a new member of staff or a student which places you better to see where things are not quite right or could be better.
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