Intensive Care Unit - a change of pace

After my 8 week stint in A&E and a short period back in the School of Nursing, I went to my next placement which was the Intensive Care Unit (ICU). After the hustle and bustle in A&E, which in the end I had quite enjoyed, the relative stillness of the ITU patients was quite daunting. Suddenly the two-way chat had gone, to be replaced by the hushed shunts of ventilators and the quiet blips and peeps of life-saving machinery.

The pace of work in ITU was completely different. It was a small 6 bedded unit, very unsophisticated by today’s standards but still daunting to an inexperienced student. With only a few patients to concentrate on and 'afternoon only' visiting times strictly observed, there were fewer people in the Unit and everything seemed much calmer than in A&E. With a controlled entry system, everyone who entered the Unit had to have a reason for being there. If a patient hit a crisis the team would swarm around them, like bees in a hive, each person seeming to know their individual role. As students we were assigned to a member of staff who usually worked with just one patient throughout their shift; occasionally two if their dependency was slightly lower. Our patients were wholly dependent on the staff and the machines that surrounded them. Everything had to be monitored and recorded from urine output, to oxygen saturation to cardiac rhythm. We still had oxygen in tanks in those days and even the supply display had to be checked regularly to ensure the porters replaced the tank before it emptied completely. No running supply of air or oxygen from a valve in the wall! 

Nursing ITU patients felt like a very one-way kind of nursing, much more technical and far less patient-nurse interaction than in the wards. Lots of communication through other means though and for many nurses the relationships with patients and family through these very intense periods of illness were very rewarding. For me though, the ITU experience was less than satisfying and I couldn’t wait to go back to the hustle of a ward placement area, not least because I could stop worrying about what was coming through the doors next. It was not until years later, as a Tissue Viability Nurse visiting ITU regularly, that I suddenly understood why some people enjoyed ITU nursing so much. What had seemed so daunting as a student became fascinating as an experienced qualified nurse and as is often the way with nursing, I started learning all over again.

Next week: Compassion -  a dying art.

The thrill of A&E: armchairs, fleas and pressure ulcers

In my first year of nurse training I was placed for 8 weeks in the Accident and Emergency (A&E) department which was housed in a separate, single level building on a steep slope just down from the main hospital (St.Albans City Hospital) . It was old, shabby and poorly equipped. The small waiting room was frequently overcrowded with people sitting on narrow wooden chairs, waiting their turn. Patients requiring x-ray or admission had to leave the department and walk, or be wheeled, up the slope to the main hospital. As this required being out in the open, patients on trolleys were covered with plastic sheeting if it was raining!

The department was run by a senior sister, called Sister Plum* and a junior sister called Sister Elton. Sister Plum was small and fierce with an enormous bosom that left little room for anyone else in the tiny department office. What Sister Plum lacked in humour, Sister Elton made up for. She was approachable and cheerful, a good teacher and an active Union member. On one occasion when I reported sick with a sore throat, I was asked by the Nursing Officer in charge to provide a throat swab to send to the pathology lab for culturing as proof of illness. Outraged at what I saw as a basic lack of trust between employee and student nurse as well as an abuse of position on the part of the hospital management, I wrote to a well known nursing journal to give vent to my feelings. Then, not really wanting to rock any boats, I signed the letter ‘anonymous’ and posted it off, not expecting to hear anything more about it. The next I knew of it was that it was pinned to the Union section of the department information board in black and white print, torn from the journal's weekly letters page. Although Sister Elton pointed it out to all the staff she never mentioned it to me directly; however, I was sure she knew who the letter had originated from. This might not have mattered had I not, to my ever-lasting shame, actually had a sore throat but two tickets to see the Rolling Stones at Wembley Stadium in London. My indignation at the challenge to my integrity was so intense that I had all but forgotten that I was actually completely in the wrong. So, 30 years on I would like to say here and now that it was atrocious behaviour on

my part and I am sorry to all concerned. Guilt is a powerful emotion and rest assured the guilt I felt was enough to ensure I never ever, ever played 'hookey' again, throughout my career. Students beware, nurse tutors were young too once and we know the kinds of temptations you face!

I had been worried about my A&E placement expecting to see lots of cardiac arrests and road traffic accidents. However, my enduring memories of A&E were of more mundane things. There were lots of finger injuries (as common then as they are now) and I quickly learned how to trephine a nail bed heamatoma using a spirit lamp and paper clip and then to apply a neat and firm finger stall to keep the dressing on. There were also plenty of fractures, typically clavicles, scaphoids, tibias, fibulas and Colles (wrist) and lots of near misses in the form of sprains. Bandaging was still quite an art form at that time and we spent hours in the classroom practicing how to apply crepe bandages in the spiral, figure of eight, reverse figure of eight, ‘toothache style’ and spica methods on each-other. Fortunately, the more old fashioned many tailed bandage had been dropped by then (it looked like it needed many nurses to apply it) but we still re-rolled bandages and gauze ribbon for re-use as long they were clean. I had very particular experience of those long narrow pieces of gauze as I had been a patient myself in this same A&E as a child. We only lived two roads away from the hospital and when I tripped over a long-handled garden fork on our concrete garden path and my nose wouldn’t stop bleeding, my Mum whipped me over to the A&E to see the doctor. It must have been bad because I was a regular ‘nose bleeder’ and generally it just trickled to a halt in its own time. However, on this occasion it wouldn’t stop so the doctor packed it with what felt like yards and yards of ribbon gauze. It was pushed up and up into my nasal passages until it made my head throb and my eyes sting. I’m surprised it didn’t just start again when it was taken out a few days later. My Dad wasn’t very pleased about the whole episode because I’d bled on my new brown duffel coat and stained the new concrete path dark red as well.

More serious injuries and illnesses were few and far between but one case sticks in my mind. He was a frail, elderly man with multiple pressure ulcers around his sacral and buttock areas. The ambulance team brought him in sitting in his armchair where he’d been quietly decaying for weeks into the soft upholstery beneath him. They had to carry him through the small department waiting room before settling him into treatment room, so every head in  the place watched him being carried through. When the door was shut, we literally had to cut him out of the chair, after which we washed him as best we could. All this whilst wearing surgical gowns aprons, hats, masks and gloves because of the fleas jumping off him. He eventually ended up in theatre for a full surgical debridement to remove not only the dead skin from the ulcer bed but the remnants of the chintz cushion cover as well. I don't know what happened to him after leaving A&E, one of the down sides of working in the most transient of all hospital settings.


Trephining the old fashioned way - a bit before my time

Another of my worries about A&E was seeing a fatality following some kind of major trauma. Although I had seen a couple of dead people at Napsbury, they were elderly and died peacefully, whereas death by crash, crush, burn or whatever other means, I imagined to be very distressing for all concerned. So when a person who was BID (bought in dead) arrived outside the department in an ambulance, I asked to go and see the body. I thought it would help dispel my fears of not being able to cope although I didn’t explain this to Sister Plum who thought my request  very strange. She said I could go in on my own if I was ‘that interested’, so caught between feeling rather silly to have asked and not wanting to back down, I went out to the waiting ambulance and opened the back doors and stepped up and in. The BID (horrible term), was on the trolley with a red blanket over him (red was used to mask any signs of blood). He was an elderly man, lying on his back, eyes closed and looking very peaceful. No trauma, no blood, no ghastly re-arrangement of the limbs. I returned to the department none the wiser about major traumas and remained wary of any emergency arrivals to A&E but mindful of Sister Plum's evident disdain, I did not ask to see any more BIDs. 

Next week: all change for ITU

*Names changed