Thursday, 27 November 2008


Is it going to take an epidemic to change things?

The above news story is quite saddening, as a nurse, a scientist and a person. Some very scared people once believed this man and his (at best) inconclusive piece of research. I'm not going to go too deeply into the specifics, but when everyone - including the research team at the time - said the issue (the link between autism and the MMR vaccine) needed further research and one person says: "No, it's conclusive" surely this hints at something. Then link it to the possible conflict of interests and you should have a doctor stripped of legitimacy.

Unfortunately, Wakefield used an oldie-but-goodie within medical/quackery circles. If you tug on the emotional heart strings hard enough, with an air of threat about you, logic goes out the window. People can't think sensibly, act irrationally. In this case they continue to give reverence to this debunked research.

Until this research and the fallout from it, measles was well under control in this country. Now, as the leading story reports, it has shot up. Because it has not been a problem for a decade or two, people have forgotten how horrible measles can be. Make no mistake: measles can kill. It does, and has in this country already for the first time in over a decade.

I hope Wakefield is happy with himself. I feel sorry for the scared parents, but in the same sense I don't consider ignorance an excuse in any situation. Especially when it could lead to misery, sickness and death. It's a bloody shame.

Going somewhere else

My course gives me a chance to venture into other clinical areas whilst on placement. They usually have to be connected and you need to justify why you'd want to do it. Thus: "Because this placement is boring," or "Because there's a staff nurse on there who's well fit" don't really cut it. In the same sense, it makes little sense to want to spend time in Orthopaedics if you're on a Cardiology placement, and so on.

My current placement, as previously detailed, is not the most exciting, in my opinion. As is prempting this, my mentors are somewhat pushing me out of the aeroplane to attend as many of these sidecar placements as possible. Problem is I don't really like them.

I turn up, introduce myself and firstly see if the people you're going to be watching and working with for the duration are much bothered. You find some to be gloriously friendly and helpful, some... not so much. Most of the time, I can pick up the vague impression I'm somewhat in the way of a day's work, really. One of the main reasons for my dislike. I prefer to be working, rather than standing around looking pretty.

Now, I hear you say - you can be observing! Yes, of course, and I do. But there's only so much you can learn from observing what happens to one or two patients. For example, I was observing echocardiograms today, which are very cool. I find them interesting, the technician was lovely and I understand the results of them more. But watching two can only do so much. Now, for example, if one of my patients was going down for one I would be happy to watch that single scan on it's own as part of the patient journey through the diagnostic pathways. But watching two scans of people I don't know from Adam? I don't find it particularly useful in itself. I do like EEGs, though. It's the same concept as doing that scan on a baby, but more interesting. You get to see the heart in all it's glory, the movements it's making and the rate it's moving at. A skilled technician then takes live feeds from different angles, recording them on a handy computer. The size of the chambers is looked at, as well as how much they're inflating and deflating. More importantly, one can observe all four valves, to see if they're leaking (regurgitation) or any other defects. Not only can one observe the heart in greyscale, it is also possible to bring in some colour. Specifically, it allows a technician to observe force moving away from the probe (usually in red) and towards the probe (usually blue) and anything in between. This is important to check if any blood is moving the wrong way, i.e. back through a valve. This is a bit naughty. There's also this awesome effect when you catch a decent glimpse of the Aortic Arch with both colours going in and out of each other. Fun. I like echocardiograms, then, yes. They're non-invasive, and a bit sci-fi. Only the former point is relevant to most patients, I'm sure.

I also witnessed a modified stress test, without the exercise component. Instead, the technicians administer a drug intravenously which makes the heart put a little more elbow grease in than normal, pumping effectively harder. This chemical is used in patients for whom even a gentle walk on the treadmill would be too much. The old and the very ill, in other words. The middle ground between these two absolutes (a full on exercise test and the chemical) is a more sedate time on the treadmill. The scores received are they modified, I believe, by another handy computer. The chemical test is pretty simple. A patient just lies there as it works it's magic. Reassurance is obviously key, as the chemical can cause an increase in temperature and - since it's a potent vasodilator - can lead to a drop in blood pressure, as well as the associated symptoms - dizziness, nausea and the like. The patient I witnessed was fine for the duration of the test, sat up well and just felt 'a bit funny'. Before sitting up, however, they are injected with a radioactive dye. The patient is then given a lovely meal involving milk and a (preferably fatty) sandwich. The Nuclear Medicine Department is not emulating the witch out of Hansel and Gretel, oh no. Instead, the idea is to activate the Liver and Gall Bladder, get them moving and, by proxy, move any radioactive dye that may have accumulated in either outwards. That way, there is more chance to recieve a better picture of the myocardium when the patient is being sent up for a Gamma Camera test.

The Gamma Camera test is pretty dull, from a patient perspective. It basically involves lying there are two cameras cycle around you, in jerky movements, to take a decent set of pictures of the heart. 20-20 style, although the cameras are arranged at angles of 72, 90 or 180 degrees to each other. So hardly like a human head. The gent in charge was nice enough to talk me through what the scans mean, so I can write it down here before I forget. The GCT is useful for a few reasons. The most important one is thus: Two sets of images are taken on two different ocassions. One after a stress test, so the pictures are of a heart working hard, and the other when the heart is at rest. This is the clever bit. If both pictures show nice swathes of white and red, therefore lots of perfusion of blood to the heart muscle, it's all good. If there are 'holes' in the stress test when compared to the rest test, then it is a strong indication of ischemia. That is to say, the heart is struggling to pump blood to itself when under increased exertion. If both rest and stress pictures are holey, this implies (but does not confirm) an infarct has taken place and most, if not all, of the non-perfusing tissue is dead.*

These are the tests I witnessed. I will now be able to speak of them to patients in a much more informed manner, which is a good thing, but I can't help feel a bit at a loss when it comes to time spent. I left before the afternoon began, as I didn't think there was much more to see. I, instead, will read about the above to increase my knowledge on the subjects. Additionally, I can't help looking forward to my next placement back on an actual ward, doing what I consider more valuable work.

* A different nuclear method, a Thallium test, can later give an idea how much of this tissue is fully dead, and how much of it is in hibernation.

Monday, 24 November 2008

Nazi Nursing

This is all at once saddening and maddening.

The four pillars of ethical practice and the views of far right, racist, nationalist politics do not mirror each other. In fact, they clash quite massively with each other. This idea that one could treat every person with dignity, respect and acknowledge their autonomy is somewhat ruined if, underneath, you want to unlawfully throw them out of the country for having skin that isn't white.

This is typical behaviour from the NMC. I am a constant critic of the lack of political opinions and stance from nurses in general, who seem to play the angel/martyr card as a get-out clause. But this is typical hands-off work by the NMC.

Political freedom is one thing. The freedom to believe in things which go directly against all nursing (and, to a point, the NHS) stands for is completely different. I believe in socialism, partly, and I definitely believe in trade unions. This political belief does not throw around slogans such as 'Rights for Whites' or does not involve violence and intimidation against it's opponents. It does not advocate hate or any other inequality. There's a fucking difference. No pity for fascists, no quarter for fascists. Just call me old fashioned.

Wednesday, 19 November 2008

Paternalism for Prostitutes

It's lovely to see that, even from women within the snake pit of national politics, patriarchal, paternalistic bullshit is still alive and well.

A sex worker on Channel4 News was not the first person I heard express dismay that the government commission - in its quest to make the world safer for sex workers - did not really talk to... sex workers. Shome mistake, surely?

Well, not really. It simply turns out that the idea of 'We Know Best' still reigns supreme. The ministers went on a tour of different countries to see how they handle the issue of sex workers. In Holland it's legal, as many anecdotes from just as many young men who go there for a dirty weekend will elude to. In Sweden it's completely illegal, etc.

The government chose to copy Finland with this new legislation. Legislation which has, to be polite, had a limited effect in that country. Legislation that sends out mixed messages. It doesn't appear to much protect the women it is designed to protect (and the personal opinions of sex workers I've read backs up this idea) and yet it - like most anti-prostitute legislation - force many sex workers underground.

People involved in the sex trade should be supported, in my opinion, and this new bureaucratic mess will certainly not do much to that end. KGM basically had DoubleH admitting she wanted prostitution completely banned, in theory. What else could be expected from a woman with such a goal?

Angriogram Duty

Today I have been observing angiograms, which is nowhere near as exciting as I thought it'd be. I got to wear scrubs which I'm sure some people might find exciting, but the (heeled - why?!) clogs that went with them were utterly irritating.

Not much to report, really. I'd already witnessed a nephrostomy back in the day, so it was pretty much the same thing.

The radiographers were snotty, the nurses were nice and the main consultant I observed was very helpful, talking me through and asking me questions (woo) on the scans the unit performed that day. Other than that, things were quite dull.

A massive ball was dropped, though. A rather rotund patient got all the way to the table before it became clear they would be too heavy for the mechanisms. So, at the eleventh hour, the whole procedure had to be scrapped. The patient was surprisingly good about it, but quite a mistake to be made.

On that note, another overweight patient was being scanned when the consultant noticed a quite horrific note in the patient file from a surgeon back in 1981. I paraphrase:

"Patient is embarrassingly overweight, with plump, reddened cheeks and presenting stinking of alcohol but appeared clinically sober."

It went on. How things have changed... I hope.

Anyway, I'm quite bored of my placement. And have yet 3 and a half weeks to go. Nil desperandum.

Sunday, 16 November 2008

The Last Week

So, I spent some half days doing (what I know feel is) the same old Health Promotion business. Home visits with interesting people with interesting problems, which are very fun, really. But it's hard to ignore the fact that you're reading them the same check-list, over and over. The skill there, and the skills the people I work with really have, is keeping the procedure nice and fresh.

I spent Thursday and Friday on the Heart Care Unit, which was fucking awesomely out of this world. Critical Care really is my cup of tea, if this hasn't been made clear through my usual ramblings. And given my previous experience in Cardiology, it was a comparatively good deep end to dive back into. I had worried, over the Summer holidays and my current placement (involving few clinical skills) that I would be clinically void. Worse still, I feared I'd lost my edge communicating with and providing care for critically and acutely ill patients. But I haven't! That's exciting.

I had some really good experiences. I worked with the same senior staff nurse for both shifts, who was both a great nurse and a superb teacher. I impressed her with my knowledge, enthusiasm and willingness to get involved - another three things I'm glad haven't waned.

Yes, HCU was very good for me. Given I have an exam coming up about managing care for someone who has just suffered a cardiac event, it was a valuable education experience. The HCU in my current hospital is quite well staffed, which is excellent to see, and there is a more proportional population of men in the nursing side of things, a fact that fills me with optimism. Other than that, it simply reminded me of how much I *LOVE* the core.

This isn't to say it was easy. There were patients who had lots of things going on in their lives, and needed high levels of support on every level - social, spiritual, psychological and medical. This is one of the hardest parts of working in acute and critical care, but it's also one of the most important ones that I'm eager to learn more about, no matter how difficult.

This week I have to try and sort out some spoke placements, which is fucking awkward, especially when it comes to sorting them in other hospitals who are not 100% connected to my place of learning. I can't help but feel my current placement is eager to ship me off for as many away days as possible, which seems a bit besides the point, but we'll see. This week isn't all doom and gloom, though - oh no! Firstly, I'm going out on the tiles tonight to see one of my favourite ever bands. Second, I get to attend and observe some angiograms on Wednesday, which will be lots of educational fun. I look forward to it.

It's been a while.

So, yeah. Apologies for the lack of Mother and Baby conclusion. Although, truth be told it wasn't that interesting. I spent some time on the midwife-led delivery unit, and saw absolutely nothing, alas. A couple of baby examinations, that's about it. Not much that eluded to education and experience, but that's the way it goes, sometimes.

Dr. Crippen has been chronicling re: midwives/"madwives" recently, and it's certainly an interesting debate. Especially the comments.

I'd say the education of student nurses is quite biased towards midwives, in my experience. We share a council, obviously, which might effect things. But generally I don't mind them. They do a difficult job under often difficult conditions. Dr. Crippen has a big ying against Independent Midwives, with some good reasons, but it's not all that clear cut. It's not baddies VS. goodies or anything so simplistic.

The thing which I dislike is the view of the - ahem - feminists over at TheFWord. To state, quite simply, "we decide what is anti-feminist" is hilarious. Their arguments on 'medical rape' are also quite amusing. I seldom agree full on with Dr. Crippen, but his point rings true: Their arguments rely on eliciting emotion, overriding logic and good sense. They speak as if the waters are always clear in modern medicine and midwifery, and like decisions are typically easy to make. I am in no way condoning patriarchal, paternalistic, top-down care or anyone. That's bollocks. What isn't bollocks are the 4 pillars of ethical practice. 'Feminists' over at the F-word state that people in the medical and nursing professions aren't God, which is certainly correct. However, as any fule knows, sometimes judgement calls have to be made. Beneficence can overrule the three remaining principles. Worse still, in the case of pregnancy there are two lives to consider. Doctors, midwives and nurses have to make calls on these issues, often in split seconds, and I believe such decisions are a million miles away from the coffee table debates that concern these 'feminists'.

Wednesday, 5 November 2008

Mother and Baby Day Three

Third day down. Today was my first day spent with the community midwifery team, which was interesting. There were a quite a few women who didn't attend clinics or who weren't in when we called, which was educational in it's own way. Midwifery is difficult. I sat with the whole team, elements of which I will be working with for the rest of the week, as they had what is locally known as a 'natter'. There was a bit of bitchiness as well, but this is common in my experience of women grouped together.

The latter part of the day involved another clinic, a bit more well attended this time. Bizarrely, there was myself, the midwife I was with and two medical students. I'm sure some patients would be intimidated. But most were fine with it. The medical students (the female of the pair was actually quite doc-hot) were quite cute in asking if they could discuss issues related to the patient in their tutor groups. I just give them the respect of anonymity and get on with it, personally.

Pretty standard stuff, all in all. My midwife-of-the-day told me the story of a 16 year old pregnant girl who had had to give birth in hiding from her family due to death threats. Lovely world we live in, eh? Apparently the mother had been able to reconcile, but the rest of the male side of the family refused to. The baby is probably going to be put up for adoption. Shame.

Tomorrow I have elected to spend a late shift up on the Birth Unit. This is a midwife-led part of the hospital, reserved for normal births in which few to no complications are anticipated. There are no doctors involved primarily, which is a bonus. Far too many people think doctors are skilled at delivering babies, when it's really midwives who know the score in 'normal' births. I don't like late shifts, and I don't want to ruin my 100% awesome record at helping in births, but on the optimistic side I could end up keeping the record alive and helping out another little person come into the world problem-free. I'm not sure if my hand can take the squeezing from another stressed mother, but it's worth the risk.

Tuesday, 4 November 2008

Top Up Fees Are Rubbish

The government are planning on relaxing the rules on 'top ups' within the NHS. This is a stupid idea.

Let's forget about the inequity I've blogged on previously. These are more philisophical, I suppose.

Drug Companies are not good people. They're out to make money and they do it well. Given you have to speculate to accumulate companies spend more money on advertising than they do on research. Convenient, eh?

Making money and good ethics are seldom partners. If you want to sell things, you push them on people. If you want to sell pricey drugs which NICE have not yet certified as value-for-money, then what do you do? Advertise. Prey on people in very bad parts of their lives. Bad Karma from the Big Pharma. Although drug companies are not allowed to advertise directly to patients, as they are in the US of A and are restricted in advertising directly to GPs, the internet is a virulent tool. Such companies find other days of advertising their wares, and suddenly people are informed of treatments that their GP or other doctor didn't tell them about. They feel betrayed, even though the health care professionals were only trying to stay true to the four pillars of medical ethics:

# Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
# Non-maleficence - "first, do no harm" (primum non nocere).
# Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)
# Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

Drug companies are not pinned down by such pesky ideas. They can promise people pretty much the Earth, with some presentational caveats (i.e. spin). Such freedom must be quite liberating. But is free market economics the way for the NHS to go? I think not.

Mother and Baby Day Two

Day Two turned out nowhere near as educationally exciting as Day One, I must say. Hence a shorter post.

From the outset, though, I got to see the mother, father and baby I made friends with yesterday. The two who could speak were very grateful, to which I had to play all modest (which I've learnt to do quite well, with practice) and honestly thank them for letting me play such a role in a massive experience in their lives. The mother expressed amazement when she found out it was my first birth, but her general happiness made the whole thing worth while. I didn't get to provide care for her and the baby on the ward, unfortunately, but seeing them was enough.

So. Post-Natal. A bit boring, really. It was interesting to see which kind of checks are done on both mother and baby on a daily basis, but not a day's worth of interesting. I got the strange privilege of feeling some contracting uterus' (externally, I should add) but other than that it was pretty procedural.

A note now about midwives. I have worked with two groups over two days, so this is in no way a big time judgement - just thoughts on blog-paper. A lot of the midwives I've met act as if they've seen it all, which a few might have. But sometimes this perceived expertise can come off as inconsiderate. For example, a mother was desperate to get home (for various reasons) but her baby still needed further tests. In this case, the midwives were worried about the baby's bilirubin levels. Too high can lead to jaundice which can, worse case scenario, lead to brain damage. This is a bad thing. But some of the midwives involved, out of earshot of the mother, were highly critical of her need to get home ahead of the needs of the baby. I can understand where they're coming from, but they were actually quite harsh about the whole thing when part of the problem could've been the distress of a new mother. This was not the only time something similar happened on the shift, and I personally felt it wasn't really empathetic practice. However, I'm just a student nurse, not a midwife, and so have no idea of the full picture.

An interesting day, then. I'm sitting here waiting on a call from the community midwives (who, I gather, are a completely different kettle of fish) to inform me of where to meet and what to do tomorrow. Interesting times continue.

Monday, 3 November 2008

Mother and Baby Day One

I have previously mentioned how I thought my Mother and Baby sub-placement, a week around and about the maternity and midwifery hotspots of the current Trust I'm working in, might be a waste of time. I feared this, and had images of me just stood prone not allowed to do anything, being both a man and a student on the wards for one day each. However, like most placements, it turns out it's what you make of the experience.

Today was an early shift up on the labour ward. After arriving in the wrong ward and rushing over the right one just in time, I was quickly assigned to a midwife and a pregnant woman, whose labour was in the earlyish stages, because I was more likely to see something there. Obviously, I will be keeping things ever vague to protect anonymity, but on asking the lady was glad to have me there, which is a lovely liberal attitude to hold in this day and age. I would it difficult to interact at first - asking if someone is alright when they're clearly not is just a silly idea. Generally, because her partner was unable to get onto the ward until later on, she was grateful for the support, if a bit standoffish since she didn't know me as of yet. And I was annoyed at myself for standing around very much in the style of a lemon for a bit, but then I remembered this was a total and utterly new thing for me. Maternity and midwifery is unlike standard nursing, and that's a lot to take. The midwife I was working under was equally lovely, and answered my myriad questions well, guiding me and talking to me about the issues involved. I think she was something of a (very skilled) rookie, having asked her superior for advice on a few occasions, but second opinions are important.

From starting at about 8am, the woman was in something of a state already, but still very calm, considering. She had requested no pain relief, and was simply annoyed at being linked up to machines. Things began to drag for her from there, as contractions slowly but surely gathered in pace and pain. I had found my nursing mojo and had been chatting to her by now, in between shadowing and helping the midwife. Some time later, due to somewhat suspicious clinical presentation, the midwife advised the woman to lie on the bed so we could track the heart rate of the baby and some other things more clearly. And this is when it began to kick off.

Pain and distress, although the woman was bloody well brave about it all, requesting no pain relief until much, much later down the line. The husband arrived soon, which helped, and gave us time to make some decisions. The midwife finally decided that, although it'd make the contractions hurt a bit more, a hormone delivered by IV would make them more consistent and prompt a smooth labour. The patient agreed and so off we went. Things accelerated from there - not quickly enough for the woman who was tired, in pain and generally fed up (but still immensely brave and doing everything right). I was crouched by the bed by this point, opposite her partner, having my hand squeezed in the vice-like grip only pregnant women manage to bring into play. After picking up on the things the midwife had been telling her, I took over the role of pregnancy cheerleader, helping her with her very light pain relief and the breathing she needed to be doing to 'breathe through the pain'. Once you've been an actor and learnt how to effectively improvise, this bit flows quite easily off the tongue.

Now, whereas she had not been near the 10cm of dilation necessary for delivery for the morning, the early afternoon was to herald some changes. She was the kind of woman whose status could change quite quickly and so I had half an eye on the tracing machine and the other one and a half on her, encouraging her along.

The one bad moment of the day came when a doctor came to examine her. To cut a long story short, he wanted to look and she was very sensitive. There was a point when he was inside her when she was screaming at him to wait, and I'm aware than sometimes we in the medical profession do things patients don't like and these things need to be done, in this case to assess the safety and health of the baby, but when you're being told to stop you really should. Just go away and document the patient said no, y'know? Anyway, I was close to actually speaking up when he stopped and got out of the way (and the room). Leaving the midwife, the husband, the woman and I.

From there things got really crazy from my standpoint of utter inexperience. After spending the past hour telling this lovely woman who was desperate to push NOT to push and to keep breathing, now she'd hit suitable dilation that she SHOULD push. I'm surprised she didn't smack us upside our collective heads, but she did excessively well in the push on. She was very concerned for most of the time before that the baby's head was nowhere to be seen (in the literal sense) but that soon changed. Cheered on by yours truly, primarily, the father more of the strong, silent type and the midwife busy getting things ready for what could be a quick crescendo, she pushed like a bloody trooper, and soon this beautiful little person was coming out of her. Just the head, then the face. The hard bit over, this baby was all out and the midwife was clamping off the cord, placing him right on his mother's chest. Silent at first, he soon piped up with some skin to skin contact and after a quick dry with the towel, and the woman was so relieved it's untrue. Smiles all around, despite the crying out of the lovely set of lungs of the newest person in the room. The father, elated, snapped some pictures and cuddled with the pair. The harder work over, I helped the midwife retrieve the placenta, which seemed relatively painless, and it was over. Just under an hour before the end of seemingly the longest shift I'd ever been on, and I was let go by the team, mission successful. And I felt good. The baby was absolutely beautiful, perfect even. The mother and father thanked me, to which I had to say it right back. It meant a lot to me to be involved in that special experience of their lives. I said goodbye to the baby, having a go in his father's arms after some very valuable skin2skin contact, and made my merry way home. A day of good work, indeed!

Earlier in the shift, the midwife asked me I'd considered midwifery. I said yes, but was put off by the job opportunities and difficulty getting onto the course. Asked the same question at the end of the day, the answer was still a resounding yes. I LOVE the core, even the midwifery one. They're not nurses and don't much like being associated with them, and I can see why. Their work is a world apart.