18 November 2015
The intensive care unit in the hospital is a nurse lead unit that specialises in intermediate care; most of the patients on IDA (Intermediate Dependency Area) are not intubated and are conscious. There are three bays with six beds and three side rooms for barrier nursing. The ratio of nurses to patients is 1:1. This was my first taste of hospital life. I spent time watching the nurses and healthcare assistants providing fantastic 1:1 care.
Whilst on the ward, I was taught the importance of blood gases and understanding why blood gases are an important prognostic factor for the patient. I have a better understanding of blood gases now I have seen it applied to several real patients and am now able to look at a blood gas result and have an understanding of each aspect. I also know what interventions are important to bring the body back to a ‘neutral’ level, such as CPAP (Continuous Positive Airway Pressure) for a respiratory patient if they become acidotic.
When on IDA, the alarm went off on another part of the ward. This was due to a patient becoming peri-arrest. (I had met this patient earlier in the day and had learnt they had a nephrectomy due to trauma. The patient was complaining of abdominal pain and was hypotensive so was given vasopressors to try and bring up his blood pressure). I took this opportunity to watch how a team of people come together to help these people, and what differences there are in focus in-hospital as opposed to what I’d think about out-of-hospital. They intubated this patient; I observed a failed intubation and the rectification of this situation quickly and carefully.
I followed up on this patient and found out that they had a ruptured spleen causing them to become hypovolemic because of internal bleeding.
During my two weeks on this placement, I also took the opportunity to go out with the Pain Team and the Rapid Response Team.
The Pain team is a team of specialised nurses who go out and manage pain around the hospital for patients who have comprehensive needs. I shadowed the paediatric pain nurse and learnt all about different types of analgesia and why pain relief is so important. I learnt that pain could affect people physically and on a psychogenic level. I also learnt that different pain relief can be of benefit for different things and about how, if children are old enough, responsibility should be given to them to manage their own pain as a healthcare professional (HCP) doesn’t always get it right. This is through the use of a PCA (Patient Controlled Analgesia) pump. I saw a variety of medical and trauma patients who needed pain relief. I was taught the difficulties of neutropenia in children, consequential infections and management with Paracetamol. Paracetamol can reduce pyrexia and control pain. However, then fever may be missed in children who are immunocompromised. Using a stepwise approach for these patients is tricky as the next ideal painkiller for these young patients is an opiate and dissociative drug combo such as fentanyl or ketamine.
The Rapid Response Team (RRT) respond to the sickest patients in the hospital. Measured by a MEWS score, these patients are scattered everywhere. The patient I saw whilst shadowing the RRT had gone from ‘fit to discharge’ to GCS 8 and making snoring noises. This patient required a jaw thrust to maintain a patent airway. I was left responsible for maintaining this airway whilst treatments and interventions could be organized. I jaw thrusted this patient for 45 minutes. I learnt about the importance of quick decisions and appropriate escalation when the treatment required is out of my skillset.
Another patient I saw was a patient who had gone to have lunch, desaturated and dropped GCS. The doctor thought this patient may have had a Pulmonary Embolism (PE). I used this opportunity to ask questions about PE as I had a small amount of knowledge. I learnt that ECG changes to do with PE are more likely to be tachycardia and T-wave inversions rather than the ‘typical’ S1 Q3 T3. I was also watching them challenge the patient with oxygen to try and maintain ideal saturations to see if it made a difference to his response levels.