Cardiac arrest

I was fairly lucky in my first year not to see a single cardiac arrest. Then, at the beginning of my second year, I did a placement in ICU, and from time to time was given a crash bleep, which meant that I would be called to cardiac/respiratory arrests, major traumas, and patients in extremis accross the hospital (with the rest of the team too, thankfully!). Thinking of the first time this happened, I was loving it - I kept looking at it, waiting, no, wanting for it to go off. I couldn't wait.

The first two days, nothing happened. The third day, that call finally came.

"*beep beep beeep* CARDIAC ARREST WARD 23-A....CARDIAC ARREST WARD 23-A.....CARDIAC ARREST WARD 23-A....."

For a second I didn't quite know what to do. I was in the middle of giving a bed bath with one of the qualified nurses. I look at her, still not knowing what to do, when the charge nurse sticks her head round the curtain.

"Come on then!!!"

We get going. By the time we arrive, the medical registrar is already there, and a few of the cardiology doctors and nurses are just behind us. For a while I stand back and watch, as other members of the team get to work stripping the patient, attaching monitors, inserting cannulas, doing chest compressions.

The cardiology SHO asks me to put in a guedel airway and start bagging. I've never done either before except on a mannequin. This is it, sink or swim time. I head for the crash trolley that's suddenly appeared at the foot of the bed, and grab an airway and the ambubag. I don't notice until I start inserting the airway how much my hands are shaking. I'm not conscious of feeling nervous, and I know exactly what I'm doing, so I don't know what's causing it. I connect up to the oxygen and start bagging.

Things are starting to settle down now. We're all in a routine. The CCU nurse does 30 compressions, then I ventilate twice, then the whole sequence starts over again. After a few minutes, we stop for a rhythm check.

VF.

"Stand clear!"

The ICU sister delivers a shock. All of a sudden, I find myself being thrust towards the side of the patient. Almost automatically, I mount the side of the bed and start compressing the patient's chest. At first I'm not quite sure how hard to press. I try a couple, and not much happens, so I try a little harder, and a little harder....

*Crack*

"You probably want to ease off a little bit" someone says behind me.

We go on like this for a while. I alternate between watching and compressing and running off for supplies. We get to about 25 minutes, and the patient's been in asystole pretty much since straight after that first shock.

"That's it, thanks everyone"

The ICU registrar looks at his watch and notes the time, and scribbles a few other bits in the notes. The CCU nurse fills in a form. The ward staff start detaching the patient from all the machinery and take the trolley away. The crash team all dissapear, one by one. Before long, it's just me and the patient.

I don't know what I felt, to be honest. I wasn't sad, angry, dissapointed, numb... I was just...there. I'd seen dead bodies before, but this was different. Two minutes ago, he'd had loads of people stood around his bed, desperately striving to save his life, a scene of barely controlled chaos. Now it was just me and him, and everything was so silent, so still. I stood there for what seemed like an eternity, but which was probably only about 5 minutes, when suddenly I was awoken from my daydream.

"*beep beep beep* TRAUMA TEAM TO A&E RESUS..... TRAUMA TEAM TO A&E RESUS.... TRAUMA TEAM TO A&E RESUS"

Fuck.

Of life and death

"Doctor! Doctor! Will I die?"

"Yes, my dear, and so will I!"

I've been pretty fortunate thusfar in my training that I haven't really come into much contact with the kind of specialities where people have long drawn out deaths - oncology, haematology, renal, and so on. No, most of the deaths I've been involved with have been pretty quick - "sudden arrests" (if there is such a thing in a hospital setting - something I may return to in the future), and at the very most deaths which have occured over a couple of days at the longest.

I can deal with these, they don't really get to me that much (well, not any more). The patient is zonked out, it's all over with reasonably quickly. I can cope with relatives. I can sit with them, explain that their husband, mother, brother, wife is going to die, comfort them, be there for them. I can stand and look at them sympathetically while someone utters those inescapable words - "We did all we could".

One thing I'm not very good at is dealing with those patients who are terminally ill, but in no immediate danger of dying. As I said, I don't see many of these. Maybe 2-3 a year. One such case was about a year ago, when I was on a ward. A patient was diagnosed with a particularly aggressive oesophegeal cancer. The consultant sat with him and his family, and talked a lot about "palliative chemotherapy" and "symptomatic relief" and "doing our very best for you". Of course they didn't really understand - they had no idea what was being said. I think that over the next couple of days it gradually dawned on my patient what was going on.

"Nurse, am I dying?"

Now, what to say?

I could dodge the question. Say I'll get the doctor or the staff nurse to speak to him. Trouble is, that as soon as he sees that I've taken the premise of the question seriously enough to do that, he'll know the answer, and then be left laying there with his imagination running wild, and be virtually helpless through fear by the time somebody does talk to him.

I could stall for time. "What makes you think that, Mr Smith?", or "Aren't we all?". But really, what's the use? He needs this question answering, and he's not going to settle until he gets an answer.

I could answer him. That's what he wants, what he needs. But should I? I would, but I tell myself that it's not really my place. That's a standard thought for anything which nurses don't feel comfortable doing, and end up dumping on a doctor. But what's really stopping me? After all, he knows me, and I know him - I could get a doctor to do it, but it would be just some faceless SHO who's never met him before, and probably never heard of him before reading the notes. In some ways, I'd be the best person to do it. But I don't.

Of course, the real reason I don't do it is that I don't know how. How do you tell somebody that they're dying? I could tell their wife, their son - no problem. But how do you look somebody in the eye, and say "yes, you're going to die"? You run it through your mind a million times, trying to make it sound somehow better, less distressing. But at the end of all that deliberation, you have to accept that death has an unescapable capacity for misery, and that all that is left is to deliver the news quickly.

One of the best bits of communication I've ever seen was from a senior registrar, with a patient who was rapidly heading along the line from breathlessness to respiratory arrest to intubation to death. "YOU ARE GOING TO DIE, VERY SOON. WE NEED YOUR PERMISSION TO PUT A TUBE DOWN YOUR THROAT TO HELP YOU BREATHE, RIGHT NOW". At the time, I stood at the side of this patient, who was naked (in the process of being catheterised and having an ECG), and about as short of breath as I see people come, absolutely dumbstruck. I couldn't believe he'd just done that. I thought back to the endless lectures on "communication skills", where lectures talked about sitting in a nice neutral setting, square on, perhaps with a reassuring hand on their knee or a sympathetic smile, breaking the news gently. What a load of codswallop. This woman needed to know, and quickly. There was no point dressing it up. Over time I came to realise that.

And so it was with my oesophogeal cancer patient. I'm sorry to say I let him down terribly. I hope next time I'll have the guts to do the best for my patient, rather than what makes me the least uncomfortable.

Competence

I've always been interested in how it is that certain nurses are judged incompetent, and what the logical conclusion to this is. The Nursing & Midwifery Council publishes details of all the cases it hears here and here.

Of course you can never get the whole story from reading these, but it probably gives you a good idea. Some people get away with the most extraordinary things, whereas others are struck off for things which seem (to the reader at least - there may be more beneath the surface) to be minor.

There is almost a paranoia in some areas of nursing, because of this, about "covering your back". The most innocuous events are religiously recorded in the notes, the minutiae of the decisions and perceived failings of other professionals are scrupulously written down. "Incident forms" are filed whenever somebody makes a mistake (unless it's you, in which case you do your damndest to keep it quiet). Everybody is petrified that somebody is going to pull up their notes some day and think "Aha! This nurse recorded a temperature of 37.2 degrees on the obs chart but didn't think to mention anything about it in the written notes! They must be negligent - let's get 'em!"

Which is why it surprises me that something like this can go on, apparently with the knowledge of a number of other healthcare professionals, and nothing is done about it. What is even more bizarre is that this clearly negligent midwife is actually publicising the story as a triumph of her clinical skills (when it appears to be more of a triumph of good luck), and still nothing is done about it.

Whilst I'm not a midwife, and claim absolutely no knowledge of pregnancy or childbirth, I can spot a critically ill patient, and could have done a better job of keeping that woman safe. Unfortunately, it would have involved admission to a hospital, which apparently is not acceptable. Now, I'm fairly liberal when it comes to these things - I support people who want to birth at home (although I can't think why they'd want to!), and I'm all for nurses (and, by extension, midwives) developing their practice and working more independently. But stories like these just push these causes back even further, and achieve the very opposite of what they are intended to. The sooner we get rid of dangerous practitioners like this, the sooner the rest of nursing and midwifery can move forward and get the respect we deserve.

My first placement

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.

Welcome

This annoys me

On the face of it, yes it's excellent. A wonderful idea. Patients will be diagnosed quicker, and thousands of unnecessary trips to hospital will be saved.

Now let's look a little deeper...

Ignoring the fact that I've yet to come across a practice without access to a normal ECG machine, see if you can spot some of the other flaws in the article... here are a few I noticed:

• Why is it that GPs are unable to recognise ECG changes diagnostic of an MI (heart attack)? Of course, they can - anybody with even a rudimentary knowledge of ECGs can identify such diagnostic criteria. So before we even look any closer, we see that the basic premise of the article is flawed (no doubt cynics such as Dr Crippen would say this was a purposeful tactic by the BBC!)
  
• The BBC's 'Health Correspondent' also seems to be unaware that the lack of ECG changes can't rule out MI, and so in anybody presenting with symptoms who is judged to be at all at risk needs to go to hospital for serial ECGs, monitoring and a 12 hour troponin test (amongst many other things)
• Even if you see no diagnostic changes, there is no clinical suspicion of MI, any patient presenting with a sudden onset of breathlessness or chest pain or any of the other symptoms of MI is reasonably likely to need a chest x-ray, and so will end up going to hospital anyway.

So, we can conclude that this wonderful device trumpeted by the BBC is 1) Solving a problem that doesn't exist and 2) Only capable of keeping patients away from hospital when there is no real risk of anything serious (ie those in which an ECG may well have been unnecessary for anything other than covering-arse purposes)

Not that any of that lets the BBC get in the way of a good story!