Please log in or register. Registered visitors get fewer ads.
Forum index | Previous Thread | Next thread
Despatches From The Front Line Part Five: How Death Metal Saves Your Life 12:20 - Apr 19 with 3438 viewsBlueBadger

*You all know the drill by now - names and locations changed to preserve confidentiality*

An account of a day's work in two parts(because there's LOADS of it).

'There may be some hospital politics for you to negotiate this morning' is the warning from Big Jim in morning handover at the start of what will be my busiest day of Interesting Times so far.

Today's Outreach team is me and the closest thing to the 'team dad', Brian. Brian is a paramedic in his eealy 50s and one of the trust's resus officers who's joined the Outreach team for the duration of The Event. He's perpetually cool under pressure, a superb teacher and trainer and has the Trust's biggest collection of dad jokes.
There is an audible groan from Brian.
Brian LOVES Hospital Politics almost as much as he does drunks claiming to be suffering from chest pain so they can get a lift home in his ambulance(full story after the main event).

'So, you remember last night when you handed over? You remember you specifically said that NICE guidelines(and thus hospital policy) said that anyone who needed CPAP(see 'notes and abbreviations') should be on ITU?'
'Well, we've got a patient on C-2 who's on it. Don't worry, the ward girls are doing a fantastic job and I've been there half the night'

It would appear that someone has Gone Off-Piste overnight. The tale subsequently emerges. As mentioned above, NICE guidelines are(at time of writing) is indeed that anyone needing CPAP should go to ITU, even if their normal 'escalation status' is 'not for ITU'. There are a number of reasons for this, which largely boil down to the need for closer monitoring, regular reviews by a consultant or register who knows what they're doing with it, nurses who know how to drive and regular ABG testing - which would be achieved by means of inserting an arterial cannula(a specialised piece of kit needing close monitoring and trained people to use it) into someone rather than the 'ward method' of a needle into the artery.

The story emerges: The patient is in their late 70's, inevitably has a suspected covid-19 with all the associated clinical features of a developing pneumonia, has COPD, rectal cancer(with secondaries to the liver) and type 2 diabetes but is 'independent at home'(a surprisingly elastic definition). Not a good candidate for ITU at the best of times, but worthy of certain level 2 interventions(I'll add levels of care to the explanations posts). But this is not the best of times, so the patient is now sat on the ward.
Jim goes on 'the night reg saw that the day consultant's plan was for CPAP of needed and didn't want to against it, which is fair enough and frankly, I wasn't about to just let them die'
This last utterance is Jim in a nutshell. The man has a near-endless reserve of compassion - just two weeks ago he spent 3 hours in full PPE, holding the hand of a dying person in the 'hot' area of A&E because the department was busy, he wasn't busy himself and he couldn't bear the thought of this frightened and frail individual dying alone in the harshest of clinical environments. I'm not about to argue with his rationale.

A full handover ensues. The patient is tolerating CPAP well, the nurses on C-2 who have been recently trained to use NIV machines are happy and the day medics are being briefed by the night and will prioritise a review of this patient.

Myself and Brian decide to visit C-2 ASAP to ensure all is well. But before all that, the hospital politics must be waded through.
Next to arrive is my manager, Karen. Karen is in her mid 50's and a senior nurse with a background in acute medicine. She was a resuscitation trainer for years and tolerates very little bullsh1t. Within the hospital her wider role is 'head of deteriorating patient' - a role which encompasses patient safety, all sorts of training and incident reporting. Karen is both sympathetic to Jim's actions overnight and furious that someone(probably an ITU consultant or registrar) has decided to 'go rogue'. She will subsequently make my working day considerably more complicated by requesting regular updates on the patient's progress, nitpicking various bits of wording in patient notes and making 'helpful' suggestions.
Following closely behind Karen is Dave, one of the matrons who for the duration of Our Current Difficult Times, is in charge of the various 'hot' wards.
Dave is a no-nonsense former ED charge nurse in his late 40s from East London, has been a member of the Trust Outreach team and, for a senior NHS manager, pretty much completely lacking in Management B0llocks when he talks.
Again, Dave is happy that overnight, Jim has done the right thing, has already been to C-2 and is reassured that they're happy and will accompany Karen to the day's 'clinical' meeting with a view to reminding the various medical teams of current policy and best practice.

That out the way, it's time to hit the wards.
First port of call is C-2 - the patient('A') is doing 'OK'. They are looking somewhat tired, are fed up and would like a drink(the tight seal that a CPAP mask requires precludes any oral intake). Observations aren't brilliant - whilst heart rate and BP are OK, oxygen saturations are around 93%(we're targeting above 92% in most covid cases now). The nurses are managing running the CPAP magnificently but are understandably twitchy and require advice, pointers and reassurance.
Having kitting up and physically examined the patient I advise on drink and meal breaks(use the highest percentage oxygen mask you can find whilst they have a drink, some breakfast and medications), take an ABG(numbers are pretty much as I expect with a low-ish O2 but thankfully normal pH and CO2) and have a chat with the patient as to why they're receiving CPAP. I try to make these chats as frank as I can - most patients have better insight into their conditions than they're given credit for and don't take kindly to wishy-washy answers.

This all takes me about 90 minutes, all told.
Whilst I'm writing up the paperwork, the next call comes in. ED have a patient likely to need CPAP - can they send him to the wards and by the way, the medical register isn't going to see them, they're going to ask the C-2 ward consultant to see. Visions of this all spiralling rapidly out of control on top of last night's event start to form in my mind so I phone them up, ask them to hang fire on moving whilst I get some clarification on how to proceed.

Half an hour later I am kitted up and seeing the patient with Enzo, a jolly West African medical consultant who's eternal optimism occasionally fails to acknowledge what can be realistically achieved with some of our more frail patients.
'B' is, like 'A' not a natural choice for an ITU patient - whilst young(early 60's) they are also significantly disabled(left side weakness thanks a cranial bleed a few years back) to the point of needing residential care , considerably overweight and also have diabetes. Again, 'B' has a recent medical history strong suggestive of a covid pneumonia. Currently, they're awake, talking and whilst they're requiring the highest amount of O2 we can give on the ward but their oxygenation is better than that of 'A' when they were first picked up by Jim.
I offer my opinion to Enzo that I think that CPAP is certainly worth considering but I'm not convinced that 'B' is a very good ITU candidate in many other respects. Enzo agrees and asks me who should speak to the ITU team about 'B'. Given that I have several other pressing demands on my time(two patients recently stepped out of ITU and will need a review being uppermost in my mind) and the fact that there's enough of a clinical grey area over 'B' I ask Enzo to make the referral - he will probably give a better 'sell' to the ITU team than I could, plus he's a consultant(these things ares sometimes important).

I then attempt to go and grab a cuppa, do the paperwork and have a quick read through of my next two punters prior to going to see them. Before all that happens though, I get a call from Hamish, who is the ITU registrar on call - they'll be admitting 'B', somewhat to my surprise - could I facilitate the transfer please?
I put down my half-drunk tea(builder's, one sugar please) and arrange the transfer - this involves picking up monitoring equipment from ITU, portable oxygen, full ITU grade PPE and at least two other people(two to push the bed and one person to observe the patient) as well as handing over the patient to the ITU team at the other end - usually I ask the patient's named nurse to do this as it's 'their' patient and I'm conscious of the fact that my role as a specialist nurse offering support in difficult circumstance can potentially devalue and deskill the bedside nurses so I usually insist on them doing it(plus, I've probably got to be somewhere else quick sharpish after making 'delivery'), but as I've spent more time with 'B' than their name nurse it makes sense for me to do it.
This all takes me up to nearly 1400 and I've not stopped since getting in at 0745.
A further two calls for assistance come in so I do the most responsible thing I can and go for lunch.
This isn't as careless as it sounds - I'm utterly frazzled and not thinking entirely clearly. A sandwich and a drink will help me 'reset', prioritise and plan. I'm still somewhat 'flat' though as I finish my cheese and ham sarnie but a quick glance at my facebook messages changes that.

Before I tell you how - some context:
One of my favourite bands of recent times has been Virginia based death/prog/folk/doom metal act Inter Arma. If you like VERY heavy music, these guys are an utterly magnificent example of the genre. A few days previous to all this, they made a post on their FB page asking 'it's been a year since release, are y'all still enjoying the latest album'. I replied with a slight facetious 'lads, that whole 'end of the world' sound you've got going on is basically soundtracking my life as a critical care nurse right now'.
Today, in my FB message box is from a chap called 'Mike':
Mike' is Michael Paparo, vocalist for Inter Arma and, like every person I've ever met in the extreme metal scene(not loads, admittedly) an absolute sweetheart who has this to say:
'Hey mate! I’d like to send you some stuff for doing what you are doing. I have lost family to this and I appreciate immensely what everyone on the frontlines is doing. Send me an address and shirt size and I’ll send you some mail.

This is the sort of lift that not even a REALLY good sandwich can bring and the rest of the day passes quickly but not necessarily smoothly but NOTHING is going to beat me today now.

Society as a whole has key workers but we all have our own, personal key workers. On this day, Mike was one of mine.

Stay safe all.

(this day's events to be continued)

Extra stuff:

Inter Arma

Mike's band Inter Arma are not a 'big' band, they're what I would call a 'working' band who've lost out big time on not being able to tour this year but they've still taken time out to get in touch and offer their support.
Realistically there's not a lot I can do to thank Mike for his kind words and gestures but I'm going to try.
If you have any kind of fancy for VERY heavy music I suggest you go along to Inter Arma's Bandcamp page, have a listen and, if you can, lay out a few quid on an album or two.
I recommend the albums 'Sky Burial' and 'Sulphur English'(in that order).

https://interarma.bandcamp.com

The Story of Brian and the Ambulance Drunk:

There used to be a chap from the town of [redacted] who would venture out to various villages, drink a skinful and then, to save on cabs, call an ambulance claiming 'chest pain'.
On arrival at the hospital threshold he would then claim to feel better, sign self-discharge forms and stagger home(roughly 200 yards down the road).
This all stopped when Brian was paired with a very keen, very green newly qualified paramedic who decided that said Drunk Chap was showing features that needed a transfer to an Out Of Area Specialist Cardiac Centre, ignored his increasingly frantic protestations that he was 'fine' and deposited him 25 miles from home.
Apparently his missus was furious and had been previously unaware of how he'd been getting home all this time.

Levels of care:

The Department of Health (UK) produced a document in 2001 called Comprehensive Critical Care in which the levels of care are summarised:

Level 1–Ward based care where the patient does not require organ support (for example, they may need an IV, or oxygen by face mask)
Level 2–High dependency unit (HDU). Patients needing single organ support (excluding mechanical ventilation) such as renal haemofiltration(dialysis) or ionotropes(blood pressure support) and invasive BP monitoring. They are staffed with one nurse to two patients
Level 3–Intensive care. Patients requiring two or more organ support (or needing mechanical ventilation alone). Staffed with one nurse per patient and usually with a doctor present in the unit 24 hours per day.

Previously...

Part four: https://wwww.twtd.co.uk/forum/479197/despatches-from-the-front-line-part-four-id

Part one: https://wwww.twtd.co.uk/forum/478292/despatches-from-the-front-line-part-one/#0

Part two : https://wwww.twtd.co.uk/forum/478646/despatches-from-the-front-line-part-two-a-s

Part three : https://wwww.twtd.co.uk/forum/478885/despatches-from-the-front-line-part-three-w

Abbreviations and explanations : https://wwww.twtd.co.uk/forum/478292/4576782/common-terms-practices-and-abbrevia
[Post edited 19 Apr 2020 13:51]

I'm one of the people who was blamed for getting Paul Cook sacked. PM for the full post.
Poll: What will Phil's first headline be tomorrow?
Blog: From Despair to Where?

35
Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 08:11 - Apr 20 with 2945 viewsSteve_M

Thanks again for the update, very glad that you've had something external to give you a lift.

And at least you haven't had to do what some of your US equivalents have had to do:


Poll: When are the squad numbers out?
Blog: Cycle of Hurt

3
Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 18:29 - Apr 20 with 2810 viewsBlueBadger

Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 08:11 - Apr 20 by Steve_M

Thanks again for the update, very glad that you've had something external to give you a lift.

And at least you haven't had to do what some of your US equivalents have had to do:



Well, I had to tut loudly at someone in Aldi on Friday.

A 'mask' made from a kids' Paw Patrol scarf and gardening gloves. Who was barging her way past people willy-nilly with no thought for any kind of distance.

I'm one of the people who was blamed for getting Paul Cook sacked. PM for the full post.
Poll: What will Phil's first headline be tomorrow?
Blog: From Despair to Where?

0
As a follow up to this folks... on 18:30 - Apr 20 with 2809 viewsBlueBadger

...I'd be interested to know how many of you followed the bandcamp link, took a listen and enjoyed the delicate sounds of Inter Arma.

I'm one of the people who was blamed for getting Paul Cook sacked. PM for the full post.
Poll: What will Phil's first headline be tomorrow?
Blog: From Despair to Where?

0
As a follow up to this folks... on 21:51 - Apr 20 with 2749 viewssyntaxerror

As a follow up to this folks... on 18:30 - Apr 20 by BlueBadger

...I'd be interested to know how many of you followed the bandcamp link, took a listen and enjoyed the delicate sounds of Inter Arma.


Bit too heavy for my tastes, but respect to them for reaching out to you, and of course for everything you are doing.
Words can't really express how I feel about it, I just hope when all of this is over, people learn to respect all members of the medical and care professions a hell of a lot more.

And, seeing they are playing in France and Germany in June, I really hope you will get some time off to go and see them.

Maybe it would be a nice TWTD present, if it were at all possible, to get you there, of course if their tour isn't cancelled.
1
As a follow up to this folks... on 14:20 - Apr 21 with 2551 viewsDurovigutum

As a follow up to this folks... on 18:30 - Apr 20 by BlueBadger

...I'd be interested to know how many of you followed the bandcamp link, took a listen and enjoyed the delicate sounds of Inter Arma.


I thought my laptop speakers had broken.... Far too heavy for me, but each to their own.

Thank you for the commentaries - I have shared with friends who also appreciate the reality check.
0
Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 18:27 - Apr 21 with 2517 viewsfactual_blue

You really should speak to a publisher about these. Perhaps Phil could contact HarryfromBath, who must have contacts.

I'll take the film rights.

Ta neige, Acadie, fait des larmes au soleil
Poll: Do you grind your gears
Blog: [Blog] The Shape We're In

1
Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 12:09 - Apr 30 with 1773 viewsSouthBucksBlue

Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 08:11 - Apr 20 by Steve_M

Thanks again for the update, very glad that you've had something external to give you a lift.

And at least you haven't had to do what some of your US equivalents have had to do:



Truly inspiring BB.
0
Despatches From The Front Line Part Five: How Death Metal Saves Your Life on 07:00 - May 1 with 1700 viewsWeWereZombies

Just one quick question after finally getting around to listening to the Inter Arma; do you ever place any of your patients in the middle of a chalk pentagram and waft smouldering sage brush over their recumbent bodies?

Poll: Luton or Dubai ?

1
About Us Contact Us Terms & Conditions Privacy Cookies Advertising
© TWTD 1995-2024