Return

I've been meaning to write ni this for a while now. Thank you MMW for your comment, it was a kick up the arse, I'm sorry it's taken so long to write since then.

Since I last wrote I have completed my nurse training, started working a staff nurse in a busy SW London hospital, ended a 4.5 year relationship and began a new one.

I've wanted to write so often recently, but this has usually been following a bad day at work where the madness of the NHS boils my blood! I still LOVE my job and it's partly for this reason that I've not written. I don't want this to become a negative "The NHS is Bad" blog.

However, I suspect many of my posts will remark upon the state of the NHS and nursing today. I will endeavour to include something positive, because the job is not all bad and there is still a lot of reward in it.

I was recently asked a question about the current NHS, red tape and political correctness. I've decided for my first post I shall copy my reply in here.

Sometimes I feel that the paperwork that has sprung up from politically correct government think tanks and public inquiries impedes nursing care. It detracts from what is important; caring for the patient, not just doing tasks, but caring for them, being with them and supporting them. I wonder why a paitent's ethnic origin is important to document, as far as I'm concerned everyone should receive the same high level of care and be treated individually. 4 hourly waiting time in A&E, if a patient isn't transferred/discharged within 4 hours they "breech" and this is a terrible thing. I think they explode or something like that. I frequently run (literally) down to the A&E department to collect patients before they breech and at the cost of my own patients on the ward: their pain relief has to wait, their dressing change has to wait, their feed has to be late. I'm sure as far as the governemnt is concerned this is good nursing: the patient in A&E isn't waiting more than 4 hours, but would an extra 15 minutes really make a difference?

But then I think about Victoria Climbie (if you've not read the Laming Report I sincerely reccomend you do, it's not pleasant reading but I believe awareness is the start of prevention). That child suffered terribly and was failed by so many people and services. A lot of systems and paperwork have been put in place since then with the aim of protecting children and preventing the reccurence of such a tragedy. Surely this a good thing. Yes, it's a pain in the arse when you have 5 different referrals and telephone calls to make, but if it can prevent a child's death or maltreatment then it's worth it in my eyes. Whether it would have actually made a difference in Victoria's case I don't know, personal accountability has to come into it at some point, beyond whether you ticked boxes and filled in a referral form. But we're trying.

So, after that long-winded and off track response I agree with Doc: Too much red tape is a bad thing, not enough is worse. The difficutly is trying to find the balance. In the NHS most red tape is aimed at improving patient care. Or am I being naive? Perhaps it's aimed at improving the hospitals bank balance. Whether in reality patient care is improved, I think you'd need to look at that on a case by case basis.

I'm going to leave it there for now, though this is something I will come back to.

MMW: Please give me time to catch up with you blogs! I'm incredibly out of the loop, I can only apologise.

An Inch

I can feel a lengthy(ish) post coming on. That's what happens when I don't post for days.

• The state of the word - Don't you ever just despair? The world seems to have gone mad around me. The news is so thoroughly depressing and infuriating. I was feeling quite down about it the other night as I walked home. I was thinking maybe I should emigrate somewhere nice and work there, but I expect every country has its problems. Also, it's not just England and it's news, but the whole world's! I think I need t find an ice little island somewhere remote!
  
  
• Our young people - How have we failed them so badly? We had a 14 year old in resus the other day having been stabbed, because he'd looked at someone the wrong way and refused to give over his phone. Why do our young people think it is acceptable to do that? I was reading the news about Peckham. I just cannot understand it. We have failed these people so terribly when they feel it necessary to carry knives/guns for protection, or when they think it is acceptable to shoot someone in their bed when they're sleeping.
  
  One of the boys at my mother's centre today had brought in a machete and an axe (she is the headteacher of a Pupil Referral Unit for excluded secondary aged pupils). What these kids don't' seem to understand is that there are only two outcomes to that situation. They end in up prison for possession or killing someone, or their own weapon is used on them and they end up dead. Knives aren't any form of protection, they present more threat than these boys know.
  
  
• Fight or flight - You don't know what you would do if someone demanded your phone/iPod/money form you in the street and threatened violence, you don't know until that situation. I don't know how I would respond. I hope that I wouldn't just hand things over. I wonder if this is a wise course of action, it could see me wounded or at worst killed, but I can't help the feeling that it's the right thing to do. A mobile phone isn't worth dying for, but what about the principles? Freedom? Integrity? We work hard for what we have, why should someone be able to come along and just take it from us? Why should we be subject to violence and have to be afraid to walk the streets at night, to use our mobile phones or listen to our iPods? It's through fear that these people win, and it's a form of terrorism. I don't blame someone for not standing up to them, what use is freedom if you're not alive to enjoy it? On the other hand, if we always take that attitude we will never see change, it's like many of the other fights for out rights and our freedoms that we have seen through history.
  
  
• I looked after a girl with a brain tumour this week. She was lovely. She felt absolutely rotten but she was still polite and courteous. After gave her some IV hydrocortisone she picked up tremendously. Her brain tumour was non malignant and ha been operated on 5 years previously, it's now increasing in size again and being observed. The length they had to go to get diagnosed is scary, understandable to an extent, but still scary. I mentioned how lovely she was, I often find with the chronically ill patients that they can be very rude and demanding, particularly the sickle cell patients, but she was so polite it made her a pleasure to look after.
  
  
• Yesterday I helped distract a Sickler, not sure how old he was, maybe 8? He was writhing around in pain and crying out whilst his mother sat there and ignored him. It took very little to distract him, we played Where's Wally and he forget about his pain (apart from when the doctor came back in) and then we played with bubbles and he was quite chirpy. I know this is a situation his mother will have been in before and I try not to be judgemental but it is so frustrating to see a distressed child in pain being completely ignored by his mother. No words of comfort, no hugs, nothing. As I said he was easily distracted and it really wouldn't have taken a lot from her to comfort him, he just wanted some attention, he was feeling rotten. Maybe it's a cultural thing (Most Sickle Cell patients m Britain are of African or Caribbean descent) but it's still difficult to understand/accept. For information on Sickle Cell visit The Sickle Cell Society
  
  
• In other news... I slaved over my Portfolio yesterday and have made it look pretty impressive to my own surprise, so that is ready to take to interview. I feel like I'm getting on top of things, which is good as I'd been feeling completely out of control and I'm a little bit of a control freak.
  

Finally, I'd like to recommend the film V for Vendetta, it was originally a comic book series (I've not read it). It is superb. I don't think the plot summary does it justice and I find myself unable to adequately explain the storyline, but I would highly recommend it. This excerpt is taken from Valerie's autobiography in the film.

"But I'd only told them the truth. Was that so selfish? Our integrity sells for so little, but it is all we really have. It is the very last inch of us. But within that inch we are free....I shall die here. Every inch of me shall perish. Every inch, but one. An inch. It is small and it is fragile and it is the only thing in the world worth having. We must never lose it or give it away. We must never let them take it from us."

Nights

Right, where to start? I feel like I've been AWOL for weeks. Firstly, I have a job interview on the 16th of February, my first nursing interview and for a job I would really like. I've got some preparation I need to do for that, including writing my portfolio (that I was supposed to have maintained as I went along).

I've found out that I shouldn't have any time to make up at the end of the placement which is a relief, one step closer.

Nights have been good. The first was horrible as I'd been up since 11am and started working a 8pm that night, we literally had about 10 patients all night so it dragged and I have no idea how I made it through! The second one was much better after a good day's sleep and looking after my own (lovely) patient until 3am. The third flew by and now I'm trying to adjust my nocturnal pattern.

We have the most amazing doors in our A&E department. They seem to miraculous cure children.
[Mum] He's been crying inconsolably for hours.
[Baby] *giggle* *gurgle* *smile*
[Nurse] He's a lot happier now, must be our magic doors.
[Mum] Really, he wasn't like this an hour ago.
At which point the parent usually makes an embarrassed apology and we tell them not to worry we'll check them out anyway. Invariably, as they have no other symptoms than crying, it's because they had a tummy ache or there's is nothing detectably wrong with them.

We had one 3 year old brought in in the early hours of the morning, she'd had an ear infection and been spiking temperatures for a week that were well managed at home, but the previous night it had spiked really high and had not been controlled so the family called the LAS. When they arrived they handed over that she'd had a temperature of 40.4DegC with them. With us it was 36.4. The explanation? In the last 10 hours mum had give 6 doses of paracetamol as "it wasn't working". Fortunate they did call the LAS and come in really or I think they would have continued to overdose their child. So we did some health promotion, sang ibuprofen's praises and sent them over to the out of hours GP.

We often try to stream patients to the Walk In Centre during the day, and our of hours GP at night, when they present with something that is neither an accident nor an emergency, we have criteria for doing this. During the day the department can be quite busy and it's far better they are seen in a more appropriate setting. At night the department is often very quiet, and for many hours empty, but we will still stream the patient tot he out of hours GP. If the GP is busy we will sometimes see them in the department, they are quite flexible.

On the one hand I feel we should just see them anyway if we're not busy, why send them somewhere else where they may have to wait when we have a doctor sitting reading a magazine. On the other hand I feel that it's an important issue of education. People use the A&E department inappropriately and will continue to do so if we just accept everything that turns up.

We had an 11 year old Sickle Cell patient turn up in crisis around 20.30. She had only taken paracetamol at home, without much effect and was scoring her pain at 7/10. Sickle cell patients have a pain relief protocol that is followed in hospital and at home. She should also have been given Ibuprofen and Codeine at home but her mother hadn't and just brought her in instead demanding stronger pain killers to be prescribed. What did we do? We referred to haematology (as all SC patients automatically are) and gave ibuprofen and codeine.

2 hours later she reported that her pain was a lot better. The haematology Registrar was busy with a very sick patient on the ward and had not yet been down. The mother decided to self discharge. But throughout the 2 hours they were there she complained constantly and demanded pain relief (that wasn't needed) and wanted to know why she wasn't being seen and said her other daughter had school the next day and she couldn't be waiting around in A&E all night. Essentially she was blaming us for something that was her own fault; she could have (and should have) been at home doing exactly what we were doing. We suspect she was trying to get in and out of the department with stronger pain killers early so they didn't have to come back in the middle of the night. Incidentally she didn't return that night. It is unfortunate that the Reg was busy elsewhere (how inconsiderate of the ward patient to be so ill!), but it was her own fault that she was waiting in the department for that time when she could have been treating her at home, instead she blamed us loudly in front of all the other patients.

I'll leave it there as this is getting to be a long, ranty entry. I'm sure there have been other blogworthy things but I shall save those for another time.

Informal visits and ketamine

I had my second informal visit today. This hospital (B) is the first one I saw were recruiting, local to me and I was really interested in working there. However my visit today was a disapointment and I left the place with a really negative feeling about it, though I had expected to like it. I can't quite place what it was that I didn't like, but defnitely the person showing me around and his attitude and lack of knowledge abotu the wards, the feeling/impression I got from some of the staff, and the general atmosphere and impression of the wards. Particularly in comparison to the other place (A) where I was very impressed with the environment and the staff, and particularly the person showing me around as he was very knowledgable, seemed prepared for my visit and helpful. The person today was blowing the hospital's trumpet a lot and criticising the place where I had trained, unnecessarily I felt, I didn't feel he needed to make the comparisons. We also spoke to a member of staff who felt she'd been promised a lot in the way of traning when she joined in september but that they hadn't delivered on that. I'm put off applying as I really don't want to work there now so I just have to hope HospitalA offer me a position before HospitalB! Providing either of them do of course.

I'm a bit concerned that I'm not going to qualify on time because I have sick time to make up, and theuniversity are being incredibly slow (as with everything adminsitration) to inform my group of how many hours we'll need to do. At the moment I'm working a lot of 4 day weeks and 2 days weeks, I could easily start adding in extra shifts to make up time and save time at the end if they would inform us.

I need to stop worrying, it doesn't change anything and it's a waste of energy.

Something else about yesterday's shift that I had meant ot write about. I had my first experience with ketamine, not personally experience obviously! We had a little boy with an arm laceration that needed to be stitched and he was given ketamine to relax hima nd make him sleepy. It didn't work 100% but it worked fairly well. Apparently it puts them into a dream like state and they see odd things, but they won't remember it afterwards. This little boy kept saying he could see two mummies, and that his mummy had two supermans whatever that meant! Kudos to his mother. She was brilliant, not all parents deal with that kind of thing well particularly and their stressed/upset/hysterical response usually makes the child more distressed increasing the parents' anxiety and it becomes a bit of a cycle.

Results

Oh, one annoyance. I was due to get my exam results yesterday for my written and practical exams that I had deferred. But they now won't be available until the 22nd of January, for some strange reason relating to the moderating not posting them back in time. I don't really understand that, but it's a bit inconvenient, especially as I wanted to use them as evidence in my essay.

Assignment grumbling

I'm currently writing a (bad) ethics essay. This is an essay that I have really struggled with, not because I lack in ethics(!) but we have received little teaching in university on ethical theory and principles which adds to the difficulty in writing this essay and the way in which we are expected to write is not the way we behave in real life. The decisions we make in practice are guided by ethics and by the standards laid out by the nursing and midwifery council, but we do not have the time to stand around critically analysing and discussing each decision we make applying relevent ethical theory (such as deontology or utlitiarinism) and principles (benificence, non-malificence etc). Many of these theories and principles are second nature to some degree, nonmalficence the principle that we shall no do harm for example. I don't know that I would go as far as to say this essay is a waste of time and will have no relvence to practice, it will, but the relevence is from the research I have done into restraint and policy, not because I have applied a consequential theory to the scenario or looked at the level of autonomy the patient has.

I know, I'm just moaning. But as with many of our assignments it doesn't seem to be about furthering our development but more about showing the university we can say all the right things in the right way. What you write in an essay does not reflect your ability to be a good nurse, it's jsut learning to talk that talk.

One of the things I struggled with in the course is how little my opinion is valued in terms of assignments. We have had to write many essays on various topics throughout the course and my opinion is worthless in them if I cannot back up what I say with a reference. I understand the need for evidence based practice, and I'm not denying that there needs to be sound a knowledge base in what we write but it is disheartening to know that my opinion is only worth something if someone has said it already. Where is the room for new ideas? All the references I use, someone had to come up with them in first place.

Obesity

So one of my biggest issues at the moment is obesity in children. In the last few weeks I have come across several very obese children on the ward. I personally feel that if an adult wants to be obese, fine they can make that choice for themselves but they should not be making it for their children.

Obesity is such a well publicised issue along with healthy eating that parents can no longer plead ignorance. But what motivates a parent to over feed and poorly feed their child to the point of obesisty? And I'm not talking a little bit chubby, I am talking clinically obese. For example, a 15 year old, 1.5m tall weighing in at 110kg. A 5 year old, 45kg (yes he was tall for his age, but he wasn't *that* tall). This 5 year was due to have minor surgery, the anaethetist was talking of cancelling the operation because obtaining venous access was very difficult due to his excess fat. Fortunatly venous access was obtained and the operation went ahead. I wonder though if the cancellation would have "taught the parents a lesson"? It's not about punishment and unfortunatly it would result in the child's care suffering but clearly the parents are not paying attention to their child's health needs and what will it take for them to realise it is a problem? They obviously didn't feel it was a problem; the 2 McDonalds, a packet of crisps and a packet of maltesers the night before clearly indicated this, as did the claim that they didn't feel he ate very much.

The child's diet and weight bordered on being neglectful or abusive as my collegaues have suggested, but these were clearly very loving parents, they just wanted to make their child happy. I think something has gone very wrong in our society, material things and food are all too often used as demonstrations of affection. I regularly see it in my work, parents not knowing any other way to show thier child love other than by buying them things and giving into their every whim whether it's good for their health or not. I wonder if they truly realise the damage they're doing to their children.

I'm trying not to jump on the obesity band wagon, but I've recently realised what an issue it's becoming and it is a difficult one to address. In many cases I think it is the result of parenting that the child has become obese and it's difficult to tackle as not all parents are compliant. I also feel that at times there is a hesitency to raise the issue on the part of healthcare staff; being fat has very negative connotations in this society and it's hard to turn round to a parent and tell them not only is their child fat (we try to come up with nice words for it) but that it's their responsibility - no parent likes to be criticised. It's an issue that needs to be dealt with very sensitively and it is easy to criticise, as I'm sure you've realised through reading this. I'm not sure what the answer is but I think we need to provide education for these parents, hard facts about what the consequences of childhood obesity are, but also a supportive and nurturing environment to help them to change their child's lifestyle.

I added some new links, for those of you interested in what we're doing in Iraq there's a site that attempts to keep a record of the casualitise to date. I've also added links to 3 blogs which I'm following with interest, I hope I've not broken any Blogging etiquette in linking.