Sunday, 22 March 2009

Second Week, ICU and bedpans.

This post isn't really about bedpans. It's just better if these things come in threes.

Although, come to think of it, my patient today (my third one, something I'll touch on in a bit) did think the bedpan/bowl I was holding with a hat. We decided it'd pass for formal wear if it was painted black.

Well, sort of we. They are a funny one.

I post today for various reasons. My mentor gave me a few hints of things to reflect on, and I will choose to reflect on here, in my trademark glib manner before putting pen to paper and going all serious and shit.

The long and short? A Band 7 spoke to my associate mentor, and I, like we were pieces of shit on their boot. Backstory:

We started the day in a side ward, with one patient who had been placed there with a suspicion of C. diff, although by the time we came on shift she had quite formed stools, so we were happy. This patient was a bit... mobile around the bed. And unresponsive to commands, but generally well. Quickly as possible, we did all the transfer stuff for a step down to NeuroHDU.

This was all the more rushed as there was a patient in surgery, awaiting the bed we were clearing. Excited, I was going to see an admission and discharge on one day! This stuff is important so you're not completely clueless, really.

The fly in the ointment was a logistical one*. There was a member of the nursing team close to finishing their supervised placement who it was said would take point on the admission. My actual mentor said I could still be there, though, and that was agreed by all the staff on the floor to be a good idea.

However, Band 7 comes along and - with one of those laughs you want to swap, in your head, for the sound of rancid, jagged nails down a blackboard - gives this: "I didn't realise you had a student with you!" (When she hadn't actually popped out from behind the nurse's station since start of the shift). They proceeded to tell us their brilliant plan involving my associate mentor supervising the admission and the new nurse doing it. We kinda looked at each other and said: 'That's what's happening, yes, we thought.' They proceeded to say how that meant three people would be far too much. We replied with what we'd all discussed on the floor and they said, I shit you not: "This is *my* plan. Two of you."

Enough said. Moron.

A patient I wasn't looking after, someone who has been in ICU for a while and is making some progress, decided to pull out their tracheostomy tube today and refuse to let it stay back in. It brought up an interesting ethical dilemma, as I discussed with my mentor. Patient autonomy is important, naturally, and yet there's an issue as to whether a patient can make an informed choice on below 85% oxygen saturation, something which was happening. The patient had been in ICU for over a week, too, and there's also the issue of ICU-created psychosis, which is more common than I'd thought. My third patient today had it, but - as mentioned - they are a bit of a funny one, either way. I reckon, with the ability to breathe and talk, they would probably be a bit odd. In a nice way.

The medics, in this case, decided to remove of the trachy-tube and replace it with a trachy-mask, even with the risk of desaturation and respiratory distress. They also removed their arterial line in an effort to make them feel less tied to a machine. It was very difficult the patient grievance when they could not actually talk. The patient was was mouthing something about having waited 5 days for something, but it was unclear. An accelerated step down from trachy-mask to uncuffed tube to fenestrated tube would end up with the patient being able to articulate, verbally. Only then would someone be able to decide if his ability to stop such treatment was an informed choice. And I think, ethically and professionally, the medics made the right choice.

The patient was uncooperative to the nurse, but I don't think the nurse in this case was very understanding. They displayed what I thought was a short fuse and seemed bereft of empathy. I go onto nights tomorrow so it'll be interesting to see how the patient in question is doing then, either way.

*Logistical flies in ointments are the worst kind.

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