Tuesday, 7 April 2009

Interesting times.

As the old Chinese curse goes, this is not always a nice thing to say.

It's Tuesday, right? My days are all off kilter. Tuesday. I like Tuesdays! I'll get to them later.

Monday was the aforementioned interesting. Sunday, as you may or may not remember, involved me following a patient with some neurological problems into surgery. I was with this patient again for the whole of Monday. From a nursing perspective, my mentor was very good in letting me plan out the day and - for an hour - we stuck to it. Then the doctors arrived and announced the necessary (if fucking irritating) plan of letting this patient off sedation.

For those not educated in the fine arts of critical care, this involves turning off the sedation and waiting for the patient to react, which is often by coughing and choking. With this ability to protect one's airway, the ET tube can be pulled out and replaced by a face mask ('weaning'). Patients are generally confused when 'waking up' from sedation, which is usually fine. It lasts for a little while and they settle down. Sometimes you have to be firm with them in order to keep the face mask on them and oxygen going into them, essentially life preserving treatment (the idea of taking someone from ventilation down to simply breathing room air is not often a good one for patients in ICU).

This patient had quite the chequered history. I am mentioning no names or no real details here, therefore am not breaking confidentiality I rush to remind readers. The patient was involved with the police. The patient had a history of drug and alcohol abuse, the former of which meant we needed visors, to start with. The patient was agitated on the cessation of sedation (try saying that ten times fast). This continued and continued until we couldn't keep a mask on this patient with just two nursing staff and one doctor. We, with effort, swapped them to nasal specs (those tubes which pop up each nostril) and the patient seemed to relent at pulling at them.

This was the beginning of problems. The patient was also riddled with lines used for feeding, medication and monitoring and the patient decided to turn their wrath on these lines next. This reaction is not uncommon, as the feeling of intrusions into the body isn't very nice. However, they're all vital so, short of sitting on the patient, I managed to keep them in for a bit.

By now, the patient was swearing, shouting, digging nails in and generally being abusive to us. This is not uncommon, but is hardly helpful. The doctor had left by now, leaving myself and my mentor to try and keep the patient from from hurting themselves.

This is a big issue within nursing. You can talk about the right to autonomy as much as you like in the class room, but should someone be autonomous in causing themselves large amounts of damage in (and out) of a hospital bed?

Anyway. An hour after this and the patient is still agitated, still physically and verbally aggressive. My mentor and I (after consulting the information at hand as well as the patient family, who simply laughed off the aggression as something apparently hilarious) decided the patient was actually quite orientated and just a bit of a nasty. The patient began, from then on, to verbally and physically refuse cares. During this drawn out period we were punched at, kicked at (he missed, just about, with one on each), bitten at, swore at and successfully scratched on more than one occasion. With the help of another nurse we managed to pin the patient down for long enough to change his trousers, clean up his entire body (the patient had had a bowel movement and spread it all over themselves, their catheter and their femoral central line. Faeces staying around this area? To call that simply 'an infection risk' would be like calling Nick Griffin 'a bit old fashioned'.

During this time, we were shockingly nice. Vocally and in general. My mentor continued to give the patient pain relief, despite being told - in no uncertain terms - to 'fuck offffff!'. We continued to put our bodies into the line of fire to keep the patient in bed and generally safe. We removed all the lines as quickly as possible and were generally worn out by the end of the shift.

We weren't, for the record, allowed to place 'boxing gloves' (i.e. the act of bandaging the hands) on the patient. The coordinator said, because there were two of us (I'm not supposed to be in the numbers, remember), we weren't allowed. I viewed this, as well as the whole lack of staff and support as a shocking let down for us. As did my mentor and the nurse who helped us, and we all filed incident reports after shift. Otherwise nothing'll get done. Nothing will get done regardless, but at least we tried!

More on this later.

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