Suicidal

A few months ago I was working a night shift and I was allocated the care of an 11 year old boy who was currently in A&E awaiting the arrival of an RMN. The reason for admission was that he was suicidal and had made attempts on his life that day.

We didn't really feel that our ward was the most appropriate place for this young man, usually we try to put these children into cubicles for some privacy and peace and quiet, unforutnatly the only cubicles on our ward are too far away from the nurses station and out of sight to be able to closely observe him. We decided to allocate him in our second bay in a bed opposite the nurses station. Not ideal as there were 4 other young children in that bay.

I tried to ready the bed space removing an items which could be used to harm himself, not an easy talk considering every bed space has a suction unit with lengths of plastic tubing and the child next door was an on IV infusion with long power cables coming out of his machine and plugging into the socket right next to this child's bed. I made the space as safe as possible, got a not-too-comfy chair for the RMN, pulled back the curtains and waited for the call.

When I got downstairs to the A&E department I was told that he was with his mother and the RMN in a room just out in the corridor. Then ursing staff weren't able to give me a very good history as he had been seen by the on-call psychiatry team almost immediately and they had had little to do with him. The story was that the boy had twice that day tried to run out in front of a car but had been stopped on both occasions. His mother had brought him into hospital because she was concnered abotu this and his recent behaviour. He has recently lsot a friend, and relative a little while ago and he dad was currently in prison.

I took the paperwork and joined the young man, his mother and RMN in the side room. I introduced myself and explained I was there to take him up to the ward. At this point he completely refused to come with me, said he wanted to go home, that he didn't need to come into hospital, that his mother had tricked him there.

So began an hour of negotiation. I explained to him that he wasn't in any trouble, but that his mum had been worried about him and that's why she had brought him in, and that we just wanted to keep an eye on him overnight.

He told me that he was fine, there was nothing wrong and that he didn't need to be there. Now his mother joined in, at times being constructive and helpful and at other times frustration getting the better of her and she would lose her temper with him.

She tried being the authorative parent, saying she had made the decision as his parent that he needed to be there and he would do as he was told. She tried explaining that she was concerned about him and about what he had done today. She got angry and told him how he was upsetting her.

I watched a lot of this, intervened when I felt it would be helpful, tried to placate mum when she got angry. Simon (not his real name) became increasingly frustrated, saying that he wouldn't do it again, that he didn't need to be here, said no one would believe him when he said he was okay. He slammed his fists into his lap, got up and banged his fists against the wall then sat in the corner of the room.

I tried to explain that it wasn't that we didn't believe him or thought he was lying, but because of what happened to day it was my job to make sure that he was okay, and that whilst he might feel okay at the moment and feeling one particular way sometimes this can change and we needed to make sure he was safe overnight.

Between angry outbursts and protestation he would become withdrawn and tearful refusing to make eyecontact with anyone in the room and not registering when someone spoke to him.

Every now and then the RMN would chime in with helpful comments such as "You're wasting time down here" and an inappropriate moments (e.g. mid conversation) "Let's go up to bed". I did my best to ignore this and manage to refrain from telling her to be quiet or giving her the "evil eye".

Simon was convinced that his uncle was going to come in and take him away, he kept telling us this and his mother explained that this wasn't the case and that his uncle would say he had to stay.

Almost an hour after arriving in the department I left the room to give him a few moments with his family (oh an the lovely RMN) whilst I had a discussion with the A&E nursing staff.
"You're still here?!"
"Yes, and I can see what you mean about the RMN" (They earler had described her a bit "odd")
"You know she came out of the room before you arrived asking for us to sedate him as he was upset?"
"I'd probably need sedating if I had her looking after me."

Although the child was upset, it was "normal" upset in my eyes, I would probably feel exactly the same way in his situation. He wasn't violent or aggressive, jsut very frustrated and did calm down. I felt that I had been making progress with him and that he was becoming more resigned to being admitted, however I now didn't feel the bedspace we'd allocated him was appropriate and that he needed a more private space.

We contacted the bed manager and reallocated him to a cubicle on our adolscent ward close to the nurses station. Although he was below the age the unit would usually accept we felt it would be better for him and they would be able to provide better care there.

I went back to explain to Simon and his family that he would be going to a different ward with a nice private room of his own where he could get a better night's sleep. His uncle had by now arrived and was whispering in his ear, he didn't stop when I entered the room or after I stood there for a few moment (which I found a little odd). I said goodbye to Simon without a glance or acknowledgement that I had spoken and hoped on my way upstairs that I hadn't traumatised the child too much.

He was admitted to the adolscent unit next door where I was told he had a good night's sleep, was seen by CAMHS the next morning and discharged. I don't know if he had any follow-up in the community.

Steep learning curve

Once again I cannot believe how long it has been since my last post. The weeks and months seem to be flying by me at the moment, and work is keeping me busy.

So a catch up before the main focus of this post. I worked Christmas Eve and Christmas day and all in all it wasn't so bad. Everyone was in good spirits, we had several Father Christmas' visit and we got half the unit on home leave for the day.

I had a very welcome three day break in Cornwall over the New Year which left me feeling refreshed and ready to work.

Last week I started on a new ward. It is an adolescent unit. I have so far worked for long days there and it is the reason for my post title.

The first two days were spent looking after a teenager who had been involved in a gang-related fight. It is a whole different world to the one I grew up and live in, though not unfamiliar because of the kids my mother works with.

He would swing from being polite and well mannered to being angry and refusing to cooperate. On several occasions he left the unit unaccompanied which is against our rules as we are unable to ensure their safety if they do that. Despite reprimands, explanations and assurances he wouldn't do it again he did. He would also try some of the most unbelievable lies to get permission to leave the ward, and then would become angry when we wouldn't let him. He was never verbally abusive to me and I never felt threatened by him, I actually quite liked him. Soon his anger would blow over and he would be cooperative again, now allowing us to do his antibiotic. I made him a hot chocolate and got him a packet of biscuits after one particularly difficult argument and as I sat watching him dunk his biscuits I realised that despite the bravado he is little more than a boy. He has had a really difficult home life, has been excluded from several schools, is now involved with a gang, I'm fairly sure carries a knife and is in trouble with the police, he also has some degree of mental health problems and anger issues. He is not accepting the help he is being offered and it's really sad to think where this young man may end up, because beneath that hard outer shell he is a nice boy.

On my third and fourth days I looked after a young woman who has had many previous admissions for confusion post seizures, and she has been non compliant with her medication. We had a registered mental nurse (RMN) (which makes me giggle) to watch over her, which makes my job a lot easier. Initially I didn't have a lot to do with her and was busy with three other patients but as the afternoon wore on I became more concerned about her behaviour which didn't seem like confusion you may have post-seizure but a lot more like psychosis. I was told she has presented like this before but it still didn't seem right to me. She had delusional thoughts; that she was a witch was the most common. She was having auditory, visual and tactile hallucinations; people calling her name, a man trying to strangle her. She was convinced she was dying and would not believe any reassurances that she wasn't and didn't have cancer, AIDS, wasn't having a heat attack. She became increasingly distressed and said she wanted to kill herself.

Although she had been seen by CAMHS and psych in A&E there wasn't really any plan for her, and fortunately at this point we had a brilliant psychiatric doctor come and review her. She straight away recognised our concerns and finally someone seemed to be taking this more seriously. She prescribed a very small dose of Lorazepam to try and help with her anxiety as she was highly agitated and distressed. This was given quite late in the day and the night staff reported it really helped calm her and she went to bed.

The following day we had more members of the mental health MDT assess her and the decision was made to transfer her to an adolescent mental health unit for assessment and observation. Unfortunately my patient didn't want to go and with her parents permission she was sectioned under Part 2 (I believe) of the mental health act - a process that I had not encountered before and took several hours, needing two different doctors to assess her and signs a document and the the Approved Social Worker to complete the last part.

We then had to wait over an hour for transport. When they were scheduled to arrive my patient was ready and had been persuaded and accepted the move to another hospital. Unfortunately the hour and fifteen minutes we spent waiting for transport saw her agitation increase and once again she refused to go. I was concerned she was going to try and leave the unit and was becoming a little aggressive, but we managed to persuade her back to her bed (having wandered up and down the adjacent children's wards with her) and when transport actually arrived (and I made them get rid of the trolley they wanted to strap her to!) she actually went quite peaceably.

So as my title suggests those four days were a very steep learning curve for me. At this point I would like to thank MMW for her blog. The knowledge and insight I have gained from reading it really did help me with the care of a patient that was totally outside my realm of professional experience.

False Economy

False Economy. A phrase that I've seen used a lot recently, one I've used myself. It means something that initially is cheaper but works out to be more expensive in the long term. It's something I feel can really be applied to nursing, I was going to say particularly the ward I work on that the moment but I have seen in on many wards.

Staffing. We are under staffed. We regularly have shifts where on 4 of 6 slots are filled. Sometimes as little as 3, and on a good day 5. The last couple of shifts I worked were fully staffed, a rarity, and it was wonderful. We don't have enough staff, but they won't employ more full time nurses. This however is a false economy, because with all the shifts being filled by bank and agency it would have been cheaper and far less stressful to employ another full time staff member or two.

I can't believe how many days have passed since I last posted. Time is flying by and Christmas is nearly upon us. Unfortunatly I have to work Christmas day this year, which I have to admit I'm very disapointed about, however you gotta do what you gotta do and we'll just have to try and make the day special for all the patients.

I wanted to draw your attention to a charity my hospital is involved with. Facing the World.

F A C I N G T H E W O R L D is a children's charity. It has been set up some of the UK’s leading craniofacial surgeons so that children in desperate need, living without hope in the world’s poorest countries, can have access to the very best surgery that can transform their faces and radically change their quality of life.

If you only look at two things on that website please look at the short film linked on the main page, it's in the bottom blue box with the dial up or broadband link. I would also reccomend that you go to the Case Studies page. I think what this charity does is amazing, and it is one of the few charities that has really moved me.

'Tis the season

The Bronch season.

Bronchiolitis is a common respiratory infection that affects young babies and children. Their bronchioles (smallest airways) become infected by a virus,becoming inflamed and causing a build up of mucus. Some babies become very unwell with this condition and this can mean admission to hospital.

Initially it presents as a common cold which then worsens and affects their breathing. They develop rapid breathing, a rasping cough and a raised heart rate.

In some children these symptoms worse and they have increased difficulty in breathing. They have a rapid respiration rate, will be using their accessory muscles to aid their breathing, this can be very tiring and lead to exhaustion, in this case they will need support in hospital. They may also struggle to feed as they find they become too breathless.

Treatment. We give oxygen. We sometimes give inhalers, though these don't always work well. CPAP - a form of non-invasive ventiliation to assist breathing. IV fluids to correct/prevent dehydration. Nasogastric tube feeding until we can reesatblish breast or bottle feeding.

I hate Bronch season with a passion. Bronch's are incredibly hard work.
a) They may be on oxygen. Hopefully you get a set of nasal prongs in and hopefully get them stuck down and then hopefully they won't keep trying to pull them out. If they're on oxygen they require hourly observations and being on a sats monitor.
b) Sats monitors are a great tool for nurses. They allow us to continously monitor the childs heart rate adn oxygen level. When there's a good trace. Which there usually isn't because the child is kicking it's foot around and doesn't like have the plaster attached. You will also notice that monitors increase parental anxiety. They become number watches, obsessed with the heart rate and oxygen levels, but they lack the experience to intepret the machine and it's readings, to knwo when it's accurate and when to be concerned. They require more reassurance and will frequently buzz for you worried that their child's oxygen level has dropped. Of course there is the opposite extreme. The parent who has seen you silence the machine before and think it's okay for them to do the same, not realising that you're also making an assessment when you do that. You then pop along an hou later to discover the child's oxygen levels are too low. Sometimes they even turn it off without telling you, because the alarm was annoying them.
c) NG feeding. This may be a continous feed or a bolus feed. Blous feeds take a considerable amount of time on an already busy shift. If they're very unwell we have to reduce their feed because the expanding stomach restricts the lungs ability to inflate, and if they're really very unwell we may stop feeds altogether and rely on IV fluids for hydration and the occasional comfort feed. This leads to d)
d) Irritable. Bronch babies, when they are unwell, are some of the most irritable and unsettled children I have come across. They feel rubbish, they're tired phsycally from the effort of breathing, will probably not be sleeping well and they're hungry. They are some of the hardest babies to settle, a nightmare for the parents and in turn for the nruses when the parents are at their wits end and asking you for a solution (or jsut ignoring thier child)

Where I'm working we put Bronch's into double bays. They're infectious, but with the number of Bronchs we have we double them up as they both have the same illness. Unfortuantly we so often seem to have one sick one and one slightly better one. Sick baby and mum keeps slightly better baby and mum up all night, causing frustration for everybody. Then slightly better baby goes home, and sick baby becomes slightly better baby and we get a new sick baby in and it begins again.

Hospital is the worst place to get a good night's restful sleep!

Structure

Well after MMW's suggestion I'm writing a post on the structure of nursing. This is based on the heirachy where I work now, though I think it will be fairly similar all over - it certainly was similar where I trained.

So, there are three types of nurse you'll come across on the ward.
Staff Nurse, someone employed permanently by the hospital - that's me.
Bank Nurse, someone who has signed up to the hospitals internal nursing agency - that can also be me - usually someone who already works in the hospital and wants extra shifts.
Agency Nurse, someone who works for an external nursing agency. Sometimes they're good, often not too bad but slightly more a hinderance than a help, and occasionally absolutely awful.

Why would someone want to work for an agency? Agency nurses get paid higher rates than Staff or Bank nurses, (Bank nurses earn slightly more than Staff Nurses) - the ward waits as late as possible before "putting the shift out to agency" in the hope someone cheaper will agree to do it.
Less responsibility.
Agency nursing is flexible; you can work which shifts you choose.
However the downsides to Agency nursing:
Shifts may not always be available when you want them
Depending on where you work you will be unappreciated and looked down upon, you also run the risk of being given the difficult patients or those no one else wants to look after - I don't believe this is true of where I work now, I think we treat our agency nures fairly well, that's why we have some regulars who keep coming back to us.

On the ward I work on we have 20 beds, this closes to 15 over the weekend. On week days we (hopefully) have 6 staff, on week nights 4 staff, and on weekend days 4 staff and weekend nights 3 staff. At night you can expect to care for 5 patients, if fully staffed. On days 3-4, if fully staffed.

Some of the patients we have require a lot of nursing intervention, 1:3 may not sound like a lot but depending on the patient the workload can be very heavy, and day shifts are always busier than nights. That being said, nursing 5 patients overnight can also keep you very busy. We have a lot of jobs that are supposed to happen on the hour, an example of the hourly jobs you may have to do for 5 patients overnight could be: 3 pump readings, 3 sets of observations, 1 set of inhalers (on some hours rising to 2), giving a feed hourly or two hourly, plus on various hours on top of that IV antibiotics (which I'm not yet trained to do), observations for other patients, medications. I often find that I'll have just finished my hourly jobs just in time to start the next hour.

However, I have trailed off the topic for this post. Sorry for that rather boring interlude! Back to structure.

Band 5 - This is a Staff Nurse, generally speaking, in their first 5 years of nursing, after this point to progress through the pay scale you would have to move up a Band. You have lower and upper Band 5's, which represent the old D and E grades, basically those with more or less experience. These lettered grades were removed with Agenda For Change, but we still refer to them.

Band 6 - This is a Senior Staff Nurse, in some places they may be called a Junior Sister or Charge Nurse. They have more responsibility than us lowly Band 5's, which is one reason why some nurses choose not to move onto Band 6 despite reaching a cap in their pay. Where I work we currently have 5 Band 6's, two of which are very part time (2-4 shifts a month).

Band 7 - This would be the ward Sister, or where I work Ward Manager. The Ward Manager is similar in role to Sister but as far as I can work out is less clinical and more office based. We have one Ward Manager.

We have recently had a Modern Matron come into post, in the last few weeks, this is a very new position for us and I'm guessing it is a Band 8 position. He previous was a Ward Manager, and now manages the whole of children's unit with Ward Manager's in each ward.

Now, that is our basic structure for ward Staff Nurses and Managers, but there are a couple more "important" roles. During the day we have a Paeditric Bed Manager, and you've guessed is he manages the Paeditric Beds. He keeps tabs on all the beds and cubicles available across the unit and the demand for them in A&E. Any child admitted during the day needs to go through him, and he makes the decision about where to allocate them. At night this role is filled by the Site Manager, who has the unenviable job of being Site Manager/Bed Manager for the whole of the hospital. They need to keep track of the admissions, discharged, allocations and transfers as well as any staffing issues that may arise. Our last key person is the Senior Nurse (not to be confused with Senior Staff Nurse). This person carries The Bleep, and their responsibility is staffing; if someone calls in sick they have to speak to the Senior Nurse, they have to be aware of staffing across the unit and make decisions about where to send nurses to cover if we're short staffed. This is usually a Band 6 or above nurse, though some of our more experienced Band 5's will also do it. This is also on top of thier normal patient workload as staff nurse that day or night. Oh, and we have a shift co-ordinator in charge of every shift, this can be almost anybody who's been there at least a few months!

So that's how it all works. Kind of! I know this was probably a bit of a long winded and boring post, but I think understanding what goes on "behind the scenes" will make my blog make more sense!

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.

Easy IO

Well I was supposed to hear today about my job, but didn't receive a phonecall. The third referee I asked them to contact hasn't been contacted so it gives me a good excuse to call tomorrow and find out what's happening.

Had a really good resus yesterday, a baby with a heart defect that came in blue and with a horrible blood gas, very acidotic. Was transferred to a PICU at another hospital, but for a while it didn't look like he'd make it.

They used a machine called an Easy IO, it essentially drills an intraosseous (IO) needle in, instead of you having to twist it in yourself, really good bit of kit - makes it a lot easier and is much securer.

An IO needle is one that goes into the bone and into the marrow, it's used in emergency situations when you are unable to gain venous access (You just whack it in the child's leg below the knee and start twisting/corkscrewing it in). Sounds pretty painful, and isn't the nicest sight to watch, but the children are usually so unwell by this point that they're unconscious.

I also had a little look at an open chest - that was pretty cool, and not like what I expected. I wasn't able to get a close look though so couldn't see any of the chest organs. Whenever there is an open chest everyone is the hospital turns up to have a look as it's quite unusual.

I looked after a teenyweeny baby today, was a born a few weeks early but had a really low bow weight and has various other problems including cardiac and renal. I find the littlelittle babies a bit scary, they're so tiny and fragile; I always find holding them awkward, I feel like I'm juggling spindly arms and legs and a huge floppy head.

Productive

Well. I have had some really good shifts recently. I'm really feeling like a (fairly) productive member of the team. I'm able to do so much more than when I started; looking after patients who are a little more unwell and going to be admitted, assess/triage. I have shifts to make up, and will be doing an extra 6. On one hand I wish I didn't have time to make up on the other I am learning so much from this placement, so much more than I would have if I had made up the shifts elsewhere, or not taken the time at all.

We've not had any really interesting cases recently. I've seen a couple of good dislocated fingers, fingers bent in strange positions. I did a dressing on a 2 year old who had ripped two of their finger nails off... owwww... I'm not good with nails.

I may just be easily amused, or having a giggly day, but had a few funny conversations with parents who speak bad English (as most of our parents do). It makes it so challenging sometimes, but it can also be funny.

A child came in, mum started out by telling us he'd had an operation on his nose a few months ago (that turned out to be a tonsillectomy) so we assumed, naturally, that there was some problem related to this. No, he'd fallen over and bumped his forehead.
Nurse: "How did it happen?"
Mum: "Today"
Nurse: "No, what happened, how did he do it?"
Mum: "Today"
After about 6 different phrasings of the question we established how it had happened.
Nurse: "Has he had any medicines today?"
Mum: "No"
Nurse: "No Paracetamol? Calpol?"
Mum: "Yes"
Nurse: "At what time?" *points to the clock*
Mum: "2-3"
Nurse: "Which is it, 2 or 3?"
Mum: "1"
We eventually, once again after asking several times, that he'd had 1 teaspoon at 2pm. I really do just find these conversations amusing sometimes.

One thing that really annoys me, and please if ever you see a doctor doing this tell them not to, they stab a child (with a needle) and miss the vein so they use an alcohol wipe to press on it to stop the bleeding. You're already hurting and distressing the child, must you rub alcohol into the wound? It stings! It only takes a little organisation to bring gauze over, it's just so unnecessary, and does make me cross.

Finally, I have a job interview on Wednesday for a job I applied for back in January. I'd heard nothing, and to be honest I thought it was a rubbish application, so I didn't think I'd been shortlisted. I don't really know a lot about the job, the advert wasn't very specific about the clinical area, but that gives me something to ask about on the day. Later that night I'm catching a coach down to Cornwall to join my holidaying family for a long weekend.

Something I said

I was assessing a teenager who had, a number of years ago, had all thier fingers/thumbs amputated at the knuckle. I knew this from looking at the patient notes, and also from looking at his hands and the scarring - he had no fingers.

Part way through the assessment, after taking the history, I went to take his physical observations, including his pulse. I went into autopilot, started unfolding my pulse-oximeter cable and said...
"Can I borrow a finger please"
I was mortified. The patient didn't have a sense of humour and didn't make a joke out of it to save me (Darn him! I thought later I should have said "Ah, it looks like we've already had them" but I don't think he was the laughing kind).
Instead I fumbled my way through with...
"Or, we could use a toe..." (I later read more of his notes and discovered he'd had a partial foot amputations too)
"Or I could just stop being so lazy and do a manual pulse. That's the problem with these machines, you get so used to using them that you become lazy and use them even when you don't have to"
Ramble. Ramble. Just keep on digging Angela.

Some good ones.

We've had some good ones recently.

Possibly the best worst reason for bringing your child to A&E. A 13 year old was brought in by his parents because he'd put something into his ear... three years ago. Why did they wait so long to come in? He'd only just told them. He had no history of ear problems and unsurprisingly there was nothing still left in his ear.

We had a 15 year old brought in from school yesterday by LAS because he was vomiting. Turns out he'd smoked some cannabis on the way to school. He was looking pretty rough and feeling quite sorry for himself. Guess he won't be doing that again in a hurry.

A 2 month old was brought in because he hadn't slept in the last 3 days, at all. (Yeah, right.) So presumably the parents haven't slept in the last 3 days either? Or have at least taken it in shifts so can observe their son's lack of sleep.

We have a television in the waiting room that we can play children's films on, one of the Registrars was walking through and suggested that we should change the channel as "My daughter is a prostitute" on Jeremy Kyle might not be the most appropriate viewing! Sometimes I'm surprised at what makes day time television and what is shown after the watershed.

Almost there

I feel that I should post as I have neglected my blog for so long!

My placement is going really well, I have only 4 and a half weeks left but have discovered I need to make up another 6 shifts that I owe. I have very nearly finished my Portfolio essay and now it feels the end is in sight! By the end of April I should have all my work submitted and my hours done.

I'm trying to think if we've had any interesting cases recently. There was a little boy who had swallowed a 5pence coin yesterday, his younger brother had put it in the back of his mouth and whilst his mum tried to remove it he swallowed it! We used a metal detector to locate it, but as this method is currently being audited we had to confirm with x-ray. It was in his stomach and not causing any problems so nature is left to take its course. Fortunatly it was only a 5pence piece and not a 50 pence!

We had an unpleasant child yesterday, about 4 years old, who decided to hit me in the face and knock my (new) glasses onto the floor and then kicked me. He wasn't frightened, in pain or struggling to get away, just a naughty little boy who refused to apologise and smiled everytime he was told off. Mum assured us he didn't get away with it at home (yeah right) as he continued trying to hit and kick me as I fitted his collar and cuff (a foamy sling for soft tissue injuries).

The NMC is visiting our clinical area next week to audit the student placement experience/education and I've been asked to work that day, they're also auditing a clinical area I've worked in previously. It will be easy to provide a good report for my current area, they're brilliant, but not so easy for the other. It was a children's hospice that had recently lost its funding, there were a lot of redundancies being made and the service was very under used because of financial problems, it meant there was often nothing to do on the placement as there were few or no patients. I did learn some things, but most of my time was spent doing nothing at all, I think with funding it had the potential to be a very good clinical area.

X-Rays and eyeballs

I feel pretty rubbish at the moment and I don't look so good either, I've taken on my deathly pale shade as opposed to merely unhealthily pale! I think I'm jsut overly tired so I shall be off to bed shortly, but first I thought I'd write about an interesting one we had today.

A 6 year old boy playing with his cousin accidentally was stabbed in the eye with a bic biro. He came to A&E and you could just see there was something really not right about this child's eye - it looked pierced/broken, it's quite difficult to describe but it was not a smooth surface. Turns out the pen has pierced his cornea, he's lost most of the sight in that eye and is going to theatre tonight to try and save his eye and restore some of the vision. But this kid was just amazing. He was so calm and quiet, probably alittle bit in shock to be honest, but even as time went by he was still so calm. If only all our children were like that!

The only other thing I wanted to blog about today was the insitence some people have on X-Rays, people really do like them. We had one parent today he kept insisting on getting a second x-ray for his son. He has ben x-rayed a week ago for a foot injury, there were no broken bones so it was diagnosed as a ligament injury which can be quite painful. They were reviewed this week and he keps asking for an X-Ray to be done, we explained we'd already done one and there were no breaks and then he'd ask for another one! So the consultant patiently explained (for about the 5th time) that there would be no change, there were no broken bones and the treatment was just to get one with it and get mobilising (and stop being such a wuss he said to me later!).

I have been in countless situations before where poeple are asking for X-Rays for things that don't need to be X-Rayed and where the management of them won't change regardless of an X-Ray result.

My oven is beeping, but I shall write another post sometime about the belief that medicine should be able to do soemthing about everything and that we should have a pill to fix anything.

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."

The latest installment

Once again there are plenty of things I can write about. But I need to have a whinge, as I am so disappointed and upset.

My final Portfolio essay was due in in the beginning of January, I sought advice from the programme leader who emailed me saying:

"Deferring your Portfolio essay will not be a disadvantage providing you pass it the first time when you submit on the 2nd att date. If you need to resubmit it it can delay you finishing..."

I also had a conversation prior to this email where she said it's only a problem if you don't pass it on the first attempt. Well now I have found out I won't get my results until the 29th of May. 6 weeks after my course finishes. 6 weeks where I can't start working as a nurse because I won't be qualified. If I had been told this when I sought the deferral I would not have taken it, and now there's nothing I can do. I just have to hope my delayed start date won't affect my chances of finding a job. I am so cross/upset about it.

In other matters, my placement is going well. I'm now unsure about whether I have hours to make up or not, not that it matters now as I'm not finishing on time anyway. As if I didn't have enough to worry about with finishing work and finding a job.

I know this is all incredibly self centred of me, other people have far worse troubles. Like the mother of the 18month old who had to be resuscitated and transferred to Intensive Care. Or the woman in adults on Wednesday who had an accident at work involving her hand and an industrial food blender that resulted in the loss the fingers on her dominant hand.

I'm most upset because I feel I was misled, it wasn't a decision made given all the facts.

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.

Cardiac Arrest

There were several things I had to write about from my last two days at work. Had I updated when I came home on Friday I would have, but something happened first thing on yesterday's shift that will dominate this blog entry.

I was in resus checking the paediatric bay when a call came in that a cardiac arrest was on its way. The patient was a 62 year old male who had had chest pain for 3 hours. When the LAS got to him he looked very unwell so they got him in the ambulance and left straight for hospital whilst the daughter got changed, the undertone from this was that she didn't seem to realise it was serious. Just before they arrived he had a cardiac arrest and was in PEA (Pulseless Electriacl Activity) on arrival. I asked to observe the resuscitation as I have had no experience with a cardiac arrest.

After one cycle of chest compressions (from a very clever machine that looks a bit like a baby gym with a toilet plunger head hanging below) and ventilation (he was intubated and attached to a ventilator) they got a pulse back and began to try and stabilise him with a whole host of drugs. The team worked efficiently gaining venous access, taking blood tests, inserting a blood pressure monitoring line, observing his vital signs and administering medication. They were switching between two main drugs in an attempt to stabilise his blood pressure as it seesawed between high and low. By this point the family had arrived and been informed that he was a in a critical but stable condition.

He oxygen saturations were dropping and the ventilator was unable to maintain them so they began to bag him and breathe for him, he was making his own respiratory effort but it wasn't adequate. He has pulmonary oedema, probably caused by heart failure, and his lungs were filled with fluid and it was only by bagging him that they could maintain his saturations, though this also began to be less effective.

Then he arrested again, the compression machine was strapped on and they began compression/ventilation cycles again. One of his sons arrived in the room to watch, and even as this machine was forcing his chest up and down I heard the son say "Is it serious?", at this point he still had no concept of how unwell his father was, or perhaps it was the shock. They were unable to restart his heart and the decision was made after almost an hour of attempts to cease; his heart was too badly damaged, his lungs wouldn't inflate because of the fluid and he had been hypoxic at too many points not to have damaged his brain.

I excused myself at this point as the family came in to be with him, it took several explanations for them to understand that he had died and there was nothing they could do. Then the wailing began.

In university someone once told me that it is one of the most privileged positions to be in, being with someone when they die. Although this situation isn't exactly what they meant I understand it. It was incredible to see the human body in its final moments and how it fights to save itself. The team worked so well, they deal with this regularly. It wasn't dignified, but everyone in that room fought, including the patient, to save a life.

It doesn't upset me, whatever I feel is insignificant to the loss that family feels. It was sobering, but I do consider it a privilege. We talk about the wonder of birth, death in its own way is just as amazing. Dying is a part of life, I'm not suggesting we be happy about it or necessarily celebrate it, but I think I have a healthy respect for it.

The post in which I make a sweeping generalisation

On wednesday, my first day in the new department, I was walking back from the adult A&E area through to the children's side. I sometimes lack a sense of direction and found tiiquite confusing on the first day finding my way around. I frequently walked round with a grin on my face as I laughed at myself for once again walking down the wrong section of corridor and as I wondered what people thought as they saw me walking past them, turning around empty handed and walking back again.

So I was walking back to the children's side when I was approached by a rather disshevelled, shifty looking man in his 20's. My first thought was that he was either a drug addict or someone with mental health problems who'd not been taking their miedication, because I am in no way a judgemental person! Nor do I ever make sweeping generalisations! He asked me where the toilet was, and I was a little unsure so I asked if the nursing staff had told him it was this way. I then figured out where I was going and apologised.
"Sorry, it's my first day here"
To which he responded something along the lines of...
"It's going to be my last day here" and walked into the toilet, locking the door behind him.

I got a little worried at this point at the strange way he'd phrased "It's going to be my last" and I was a little concerned that he'd gone into the toilets to top himself! That perhaps he'd not been told where the toilet was for a reason and I'd just aided him in finding himself a quiet spot!

I then told myself not to be so silly and carried about my business, looking out for him the next time I walked through. Fortunatly he was sitting there looking very alive and well, if still rather unkempt in appearence. Phew!

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.

Simple pleasures

Obtaining a urine specimen from a very small child can be a bit of a waiting game. You give the parents a pot/bowl and instruct them to undo the nappy and wait, they look at you a little bit strangely but you explain that's the only way to do it and then the game begins.

This morning we had a fairly sick child that we needed a specimen from. We waited, and we waited and we waited. Nada. The child had been sick that morning and not drank much so I thought it would be a good idea to give her a some water to try and get things going. Three minutes later dad stands her up on the floor whislt he rummages in a bag, she promtly begins to wee a little puddle on the floor.
"Quick dad, quick! The bowl!" I cry excitedly.
Dad fumbles around looking for the bowl and no sooner than he has it in his grasp the little girl stops weeing. Doh! Dad and I look at eachother comiseration and lo and behold she starts up again, we get our sample, hurray. Such pleasure from such a simple thing.

Please if you are invovled in a fight be honest about your injuries and method of injury, we're not trying to get you into trouble, it's important for us to be able to assess you correctly. Sitting there non-compliantly grunting "No" and "Just me" doesn't help. Particularly when we know it couldn't just have been you there as you've already admitted to someone punching you in the face and have a mark to proove it.

We had a child in resus this morning in status epilepticus (a seizure that continues for more than 30 minutes, or more than one seizure without recovery in between), I was there to observe and lend a hand if possible. Generally my lending a hand involved passing things, holding limbs for cannulation and documenting observations. This morning, however, I had to explain the IV drug calculation to two qualified nurses when they got a bit stuck. I knew I'd done it correctly, but I'd not eaten since I'd got up almost 4 hours previously and my brain seized up a bit when I tried to explain how I'd done it. I've always been good at maths, it comes naturally, my mother was a maths teacher and I think it was passed via the placenta. However the downside to that is it is difficult to explain soemthing that you "just know" to someone else who doesn't "just know".

There are so many things I could Blog about, I see so many patients in the space of a day that are interesting in some way or another, though perhaps not to my readers! The other effect of seeing so many people is the distortion of time, or my perception of it. The little girl with the urine sample for instance; that excitement happened around 11am, less than 12 hours ago as I write this, yet it feels like days ago.

Oh, and we had laods of really cute (crying) children today. Like the one who fell 8 stairs down onto a concrete floor and had a beautiful swollen, black eye, or that one that pushed a bead into her ear and sobbed as we tried (unsuccessfully) to remove it.

First Day

I always find my first long day a shock to the system, by long day I mean 12.5 hour shift. I'm nackered! Today was good, it's a good department, friendly staff, keen to teach.

We had a trauma call for a 3 year old child who had fallen out of a window from a 4th floor flat onto concrete. Amazngly he seemed to have little injury, a few lacerations to his head, and was soon moved from resus to our ER. As I was leaving they still hadn't cleared his spine/neck and he was still strapped down, but they weren't very concerned about him. Children of that age quite often seem to bounce and come away with little injury. There was some query over how the accident ocurred but when asked the child verified the story given by his grandmother who had been looking after him. The scary thing was that in her panic she had run down to him and picked him up adn taken up him back upstaris before calling an ambulance, fortuantly he didn't seem to have any spinal injurues. The resus bay was incredibly busy with the trauma team, medics and nursing staff as well as several observers including myself who were cleared out soon after he arrived. It must have been very frigthening for that child to have some many people fidding with him and gawping, but he was incredibly brave.

We had several young children with bad asthma and/or chest infections, a very cute little baby with Sickle Cell who came in having had a floppy episode and had another one in the department and was very unwell at one point, he went to high dependany looking a loo brighter than he had before but without explanation for the episodes.

I sat with a Bengali mother who spoke very little English, not uncommon where I work. I find it one of the most frustrating things about the hospital I have trained in; the extremely high percentage of people who speak little English, if any, and rely on their children to translate for them (which in a hospital setting is rarely appropriate). I do find it incredible sometimes that some these people have come to the country, not being able to speak a word of the language, and they are so isolated in their communities that they will never learn to. However, I digress, though that was relevent I suppose to try adn explain some of my frustration surrounding that particular client group. Today I had a wonderful conversation with this Bengali mother, it was limited what she could say to me and what she understood but she was telling me about her child (who has a rare syndrome (Cat Eye Syndrome) and very complex needs) and for once I really felt like I had a connection with my patient/family, something I rarely feel when there is a language barrier.

This was only intended to be a short post, it wasn't even that much of an eventful day! I'm off to join my hotwater bottle in bed and get some much needed sleep in preparation for tomorrow. Apologies for typos. The spell check button I've only just noticed doesn't seem to be working.