'Any allergies?' It is one of those questions that as a nurse, doctor or pharmacist you should be asking all the time.
Some people know all about their allergies, how to treat them and how best to avoid problems with them. Some don't know about them and only find out about them when they are all puffied up, or red or wheezing.
And some, bless them, know all about them and think, 'Meh.'
I'm not here to judge people. My role is to tell the story.
I was stood at my little kitchen window in the on-call quarters. I was preparing something to eat and wishing I was at home so I could have a beer. Out the front of the clinic I saw a familiar sight. Some frequent flyers had arrived. That familar big station wagon. These people were so regular they deserved their own car parking spot. They were all quite nice actually.
Most people will attempt to use the clinic when it is open. That means it is often busy. Some use the clinic when is is closed and for 'Emergencies Only.' They use it then because it is not busy even if it is not an emergency. I don't mind too much as I get paid overtime for the callout, but then I'm taxed at nearly 50% so net gain is minimal.
Back to the flyers. Within a few seconds of them arriving my telephone rings, it is the security guard in the clinic.
'Hi Rob, can you come and see Frank, he err, umm, well he, err.'
'On my way.' I reply. After a while the guards for some reason like to tell you what is going on. They don't have to of course, just 'come over' is all that is required.
I enter the clinic throught he back and within in a minute I am letting the man in.
What is immediately obvious is his tongue. Usually if somebody sticks their tongue out it is a bit rude. With an allergic reaction it is potentially life threatening. The swelling can block the airway.
In the simple cascade of first aid, ABC without A there is not much point worrying about B and C. No airway means if you are not dead you will be soon. Bottom line you obtain an airway and you can go crazy with all sorts of equipment to do it.
There are stories of people cutting holes in necks, tubes that can be slide down the throat and into the lungs and when the mouth is blocked up the nose and down the throat.
The guy can not talk. His breathing doesn't sound too bad but I worried the tongue will continue to swell and occlude his airway. I put on oxygen mask on him to give him as much oxygen as I can. His wife tells me he has had some garlic butter. He has been admitted before with a similar things, twice before. He still eats it because he likes it.
As I listen to the history and ask a few questions ('How long ago? Any other allergies? etc') I draw up some adrenaline. I give the injection, rub the site and grab my airway kit.
A long thin hollow tube now gets lubed with a bit of sterile gel. I slide this into his nose and into the back of his mouth. If his tongue swells anymore it is emergency trachy time.
Amongst other problems this guy has a history of heart problems, still smokes and very large. He is on the list for by-pass grafts but because he still smokes the surgeon refuses to do them.
By the time the tube is secured in position I give another shot of adrenaline and ring the medics at the big hospital. They know I am by myself. They want me to give some more adrenaline.
The effects of the adrenaline begin to kick in. The tongue slightly reduces in size. All the excitement and huge belts of adrenaline now means his heart rate is well over 120 beats per minute. Now he has chest pain. An ECG shows nothing different compared to the hundreds already in his file. I follow the care path now for chest pain. His BP is a bit borderline for GTN ( also considering the rate related aspect) so straight to aspirin and morphine.
He is taken by ambulance to hospital. Returns a few days later. I see him as I dress one of his leg ulcers. In our chit chat he tells me the tube in his nose was the worst experience he has ever had. This from a man who has had countless operations, heart attacks, various shunts for dialysis, abdo surgery, etc etc etc.
Over the next three years I see him for various call-outs. Usually chest pain. He never touches garlic again. His wife tells me the tube in his nose has cured him of any desire to eat garlic.
Tuesday, March 31, 2009
Wednesday, March 25, 2009
Lynn Saves The Day
My second delivery story. The one where everything nearly went pear-shaped.
Written very clearly on the first page of her assessment sheet was a clear instruction. The message was that because of complications in previous pregnancies this lady must be in theatre for her next delivery.
Oh Great.
At this moment in time she is screaming her head off. She is well due to deliver and she is a long way from Dr So and So's theatre in Cairns.
In Cairns she would have a team of specialist doctors, midwives, neonatal nurses and more fancy equipment than you could poke a stick at. They also have blood. Heaps of it.
We have a bed ( two actually but one doesn't work properly, it goes up but does not go down until a really big person goes on it and then it goes down very quickly). We have some basic delivery equipment, some basic medications, fluids and a security guard and myself. Oh and today we have Lynn.
In the remote areas it is not unusual to work with relief staff. They might fly in for a couple of weeks and then disappear forever. I met Lynn about 5 minutes ago, just before our non-Cairns attending lady arrived.
On hearing the screams Lynn wanders down.
'You're not a midwife are you?' I ask. When I ask this I'm expecting a negative reply. The chances of a positive reply is so remote any bookie would take the bet. The bookie would not even lay the bet off now matter how much was at stake.Do you know how rare it is to have midwife just turn up for a few shifts?
'Yes.' she replies.
For a few seconds this sinks in. I allow myself a little hope we might get through this.
Luckily Lynn is a little more on the ball than me. She is on the telephone talking to people who understand the weird language of obstetrics. The bits I understand is the G 2 P4, massive tears, hemorrhage (the most difficult word in medicine to spell but not of concern right now), and Caesar (not the salad).
She comes off the phone and starts checking things, she does a PV and I tell her the FHR ( little guy's heart rate, which is normal). I'm trying to cannulate. Lynn is straight back to the phone. I'm dying to ask what is going on but it is obvious my questions can wait. She 'll tell me what I need to know.
I get the entonox out and it quietens the poor lady, a little. The chance of getting anything stronger at this stage is remote. Morphine or similar now to the mum might relieve her pain but big chance of a narc'd baby.
Options are to deliver here, fly out or drive out. The chopper is up north but is heading back. Drive out is possible but risk of delivery in the van (ambulance) could be a disaster. We are left with deliver here.
I turn off the air conditioner. Despite the humidity I've found cold babies are hard to warm again and can lead to further problems. We don't have a heater.
Without getting too tied up in the medical talk the ladies previous problems have resulted from trying to deliver a coconut down a straw. Even if there is some give in the straw it is too narrow and something will rip. There is a great probability the child will die if nothing is done. The risk to the mother is significant as well.
The bulging down below is beyond anything I have seen. Even fully stretched it is obvious to me there is no way a normal delivery can occur.
Lynn announces she will perform an episiotomy. Using a pair of special scissors she will cut to make the opening a little wider. By this time the pressure is causing the area to be white. The head of the baby is squashed up against the opening. His scalp is visible. At a guess I would say the diameter of the opening is about 5cm. This is only a guess from memory. It was hardly an ideal time to measure.
Lynn puts her index and 2nd fingers of her left hand between the baby's head and the woman's external organs. She is unable to get the scissors into position. The whole area looks stretched but no tear. She has to pull with the left hand and insert the flat blade of the scissors in between to baby's head and the opening of the vagina. She can not insert the scissors.
Lynn hands me the scissors. They are wet, slippy and suddenly look huge.
'I'll pull, you insert the scissors and cut.' She says, slightly out of breath
I notice she doesn't say 'please' or anything but I decide to let it go this time.
As Lynn pulls up on the labia I pop the scissors in. She strains under the effort.
'Cut, cut, cut.' She implores me. Again I note no 'please'.
I cut. Now before I complete the description I had never done this before. I think I saw it once as a student but that was a long time ago and I was probably hungover anyway. So I cut. Maybe a centimetre
Lynn watches, not quite in horror but she certainly looked surprised. She slowly moved her gaze from my incision and our eyes met. This was our 'Jaws. The Movie' moment. Instead of saying, 'We're going to need a bigger boat,' she said in a calm but very firm voice,
'A little more please Robert.'
A-ha now with the 'please'. I thought one snip would cause a sort of ongoing slice like when cutting fabric that is being held tight.
I literally had to chomp into the muscle. After a few centimetres I could tell that was enough. How could I tell. Well the little guy came flying out like a high-speed train out of a tunnel. I am sure he landed by her ankles.
After the usual clean up Lynn took the lady over to Cairns for suturing and routine check-up. Both mum, baby and midwife did well.
I often think how I would have done if no midwife was available. I like to think I would have done the same but I'm glad I wasn't tested.
Written very clearly on the first page of her assessment sheet was a clear instruction. The message was that because of complications in previous pregnancies this lady must be in theatre for her next delivery.
Oh Great.
At this moment in time she is screaming her head off. She is well due to deliver and she is a long way from Dr So and So's theatre in Cairns.
In Cairns she would have a team of specialist doctors, midwives, neonatal nurses and more fancy equipment than you could poke a stick at. They also have blood. Heaps of it.
We have a bed ( two actually but one doesn't work properly, it goes up but does not go down until a really big person goes on it and then it goes down very quickly). We have some basic delivery equipment, some basic medications, fluids and a security guard and myself. Oh and today we have Lynn.
In the remote areas it is not unusual to work with relief staff. They might fly in for a couple of weeks and then disappear forever. I met Lynn about 5 minutes ago, just before our non-Cairns attending lady arrived.
On hearing the screams Lynn wanders down.
'You're not a midwife are you?' I ask. When I ask this I'm expecting a negative reply. The chances of a positive reply is so remote any bookie would take the bet. The bookie would not even lay the bet off now matter how much was at stake.Do you know how rare it is to have midwife just turn up for a few shifts?
'Yes.' she replies.
For a few seconds this sinks in. I allow myself a little hope we might get through this.
Luckily Lynn is a little more on the ball than me. She is on the telephone talking to people who understand the weird language of obstetrics. The bits I understand is the G 2 P4, massive tears, hemorrhage (the most difficult word in medicine to spell but not of concern right now), and Caesar (not the salad).
She comes off the phone and starts checking things, she does a PV and I tell her the FHR ( little guy's heart rate, which is normal). I'm trying to cannulate. Lynn is straight back to the phone. I'm dying to ask what is going on but it is obvious my questions can wait. She 'll tell me what I need to know.
I get the entonox out and it quietens the poor lady, a little. The chance of getting anything stronger at this stage is remote. Morphine or similar now to the mum might relieve her pain but big chance of a narc'd baby.
Options are to deliver here, fly out or drive out. The chopper is up north but is heading back. Drive out is possible but risk of delivery in the van (ambulance) could be a disaster. We are left with deliver here.
I turn off the air conditioner. Despite the humidity I've found cold babies are hard to warm again and can lead to further problems. We don't have a heater.
Without getting too tied up in the medical talk the ladies previous problems have resulted from trying to deliver a coconut down a straw. Even if there is some give in the straw it is too narrow and something will rip. There is a great probability the child will die if nothing is done. The risk to the mother is significant as well.
The bulging down below is beyond anything I have seen. Even fully stretched it is obvious to me there is no way a normal delivery can occur.
Lynn announces she will perform an episiotomy. Using a pair of special scissors she will cut to make the opening a little wider. By this time the pressure is causing the area to be white. The head of the baby is squashed up against the opening. His scalp is visible. At a guess I would say the diameter of the opening is about 5cm. This is only a guess from memory. It was hardly an ideal time to measure.
Lynn puts her index and 2nd fingers of her left hand between the baby's head and the woman's external organs. She is unable to get the scissors into position. The whole area looks stretched but no tear. She has to pull with the left hand and insert the flat blade of the scissors in between to baby's head and the opening of the vagina. She can not insert the scissors.
Lynn hands me the scissors. They are wet, slippy and suddenly look huge.
'I'll pull, you insert the scissors and cut.' She says, slightly out of breath
I notice she doesn't say 'please' or anything but I decide to let it go this time.
As Lynn pulls up on the labia I pop the scissors in. She strains under the effort.
'Cut, cut, cut.' She implores me. Again I note no 'please'.
I cut. Now before I complete the description I had never done this before. I think I saw it once as a student but that was a long time ago and I was probably hungover anyway. So I cut. Maybe a centimetre
Lynn watches, not quite in horror but she certainly looked surprised. She slowly moved her gaze from my incision and our eyes met. This was our 'Jaws. The Movie' moment. Instead of saying, 'We're going to need a bigger boat,' she said in a calm but very firm voice,
'A little more please Robert.'
A-ha now with the 'please'. I thought one snip would cause a sort of ongoing slice like when cutting fabric that is being held tight.
I literally had to chomp into the muscle. After a few centimetres I could tell that was enough. How could I tell. Well the little guy came flying out like a high-speed train out of a tunnel. I am sure he landed by her ankles.
After the usual clean up Lynn took the lady over to Cairns for suturing and routine check-up. Both mum, baby and midwife did well.
I often think how I would have done if no midwife was available. I like to think I would have done the same but I'm glad I wasn't tested.
A Most Unusual Birth
Working in the bush you get to see some unusual things. I took diabetic guy's shoe off once to redress his feet only to find one of his toes left in the dressing. He did not seem too concerned. I once looked after a baby who had a fever, nothing unusual except her mother had a strange squint, still nothing unusual but the squint was new and caused by the beating her husband had given her the night before, she had a fractured skull.
Most things you can get through. All wounds need to be cleaned and either sutured or dressed. All breathing problems tend to need a bit of oxygen and transfer out. All bacterial infections need anti-biotics and viral infections just rest, panadol and fluids. Start with airway and move through breathing , circulation etc etc etc.
The one area I always did feel out of depth was birthing. Generally late in pregnancy mothers to be are transfered to the nearest big hospital. Usually Cairns for Far North Queensland. Of course there was always a few who did not want to go or wanted their children born in the community.
Where I worked there was not always a midwife available. When they were around I always treated them really well.
Anybody can deliver a child when it is all normal and natural. It is when things are not going smoothly when the experienced bush midwife is worth her/his weight in gold.
So to get to the story. Most of my actions were little tricks that by themselves might not make a difference but together can weigh the advantages in your favour.
It was a cold and windswept night. Not really but I've always wanted to write that. It was a typically warm, humid, tropical night. I was on call and it was around midnight. The telephone next to my bed rang. It meant only one thing, a patient.
Usually the security guard will inform you during the call of any of his immediate concerns. Over the years these concerns would only be dramatic stuff, 'Rob, got a bloke here with a knife sticking out of his chest.' "Can you come over got a girl covered in blood.' and ' Pregnant lady.'
Tonight the call was for the pregnant lady. I wandered over and was there within a couple of minutes. I began collecting all the usual history. In essence what I wanted to find out was if she was safe to fly out, drive out or deliver here. She had had plenty of children and with no pregnancy or delivery problems before.
A midwife or suitably trained MO might now do a vaginal exam. Not me. In this case everything is pointing towards an imminent delivery, well most things. The missing factor is lack of fluid.
I try to get as many things together. Delivery equipment and the like, oxygen and suction equipment and a tiny air viva. From the fridge I grab the synto injection. I usually like to put a cannula in mother as well, not that they all need one but it gives me something to do.
Within a few minutes we are at the point of delivery. The top of the head is beginning to pop out. It looks a little pale. Before I can think about anything else out shoots the little guy.
I am astonished. There on the bed is what looks like a pod, fairly clear and inside is a baby. I have no idea what is going on so back to A,B,C. The only way t o check the airway is to remove the 'pod' . Of course, it is the membrane sac. It tears so easily I can't believe it did not rupture on the way out. The little guy is alright. He is soon screaming.
I ring Cairns Base Hospital. The midwife listens to my story. She tells me it is not common but certainly not unusual. For a few minutes I had thought I may be famous.
We go through all the usual post delivery checks. The lady and baby do not warrant a helicopter flight ( they are too well) so it is a long ride in the back of an ambulance for mum, baby and me.
Later on I find out these babies are considered lucky and sailors especially believed they never drown. I think people into astrology and the like also have some belief about them.
Over the next few years before I left the community the little guy did okay. He came for his immunisations, never seemed to be unwell and never had any difficulties in the water. Maybe there is some truth to the beliefs after all. Maybe I will go and check what the astrologists think. Mm mm.
Most things you can get through. All wounds need to be cleaned and either sutured or dressed. All breathing problems tend to need a bit of oxygen and transfer out. All bacterial infections need anti-biotics and viral infections just rest, panadol and fluids. Start with airway and move through breathing , circulation etc etc etc.
The one area I always did feel out of depth was birthing. Generally late in pregnancy mothers to be are transfered to the nearest big hospital. Usually Cairns for Far North Queensland. Of course there was always a few who did not want to go or wanted their children born in the community.
Where I worked there was not always a midwife available. When they were around I always treated them really well.
Anybody can deliver a child when it is all normal and natural. It is when things are not going smoothly when the experienced bush midwife is worth her/his weight in gold.
So to get to the story. Most of my actions were little tricks that by themselves might not make a difference but together can weigh the advantages in your favour.
It was a cold and windswept night. Not really but I've always wanted to write that. It was a typically warm, humid, tropical night. I was on call and it was around midnight. The telephone next to my bed rang. It meant only one thing, a patient.
Usually the security guard will inform you during the call of any of his immediate concerns. Over the years these concerns would only be dramatic stuff, 'Rob, got a bloke here with a knife sticking out of his chest.' "Can you come over got a girl covered in blood.' and ' Pregnant lady.'
Tonight the call was for the pregnant lady. I wandered over and was there within a couple of minutes. I began collecting all the usual history. In essence what I wanted to find out was if she was safe to fly out, drive out or deliver here. She had had plenty of children and with no pregnancy or delivery problems before.
A midwife or suitably trained MO might now do a vaginal exam. Not me. In this case everything is pointing towards an imminent delivery, well most things. The missing factor is lack of fluid.
I try to get as many things together. Delivery equipment and the like, oxygen and suction equipment and a tiny air viva. From the fridge I grab the synto injection. I usually like to put a cannula in mother as well, not that they all need one but it gives me something to do.
Within a few minutes we are at the point of delivery. The top of the head is beginning to pop out. It looks a little pale. Before I can think about anything else out shoots the little guy.
I am astonished. There on the bed is what looks like a pod, fairly clear and inside is a baby. I have no idea what is going on so back to A,B,C. The only way t o check the airway is to remove the 'pod' . Of course, it is the membrane sac. It tears so easily I can't believe it did not rupture on the way out. The little guy is alright. He is soon screaming.
I ring Cairns Base Hospital. The midwife listens to my story. She tells me it is not common but certainly not unusual. For a few minutes I had thought I may be famous.
We go through all the usual post delivery checks. The lady and baby do not warrant a helicopter flight ( they are too well) so it is a long ride in the back of an ambulance for mum, baby and me.
Later on I find out these babies are considered lucky and sailors especially believed they never drown. I think people into astrology and the like also have some belief about them.
Over the next few years before I left the community the little guy did okay. He came for his immunisations, never seemed to be unwell and never had any difficulties in the water. Maybe there is some truth to the beliefs after all. Maybe I will go and check what the astrologists think. Mm mm.
Monday, March 23, 2009
Talkative Girl
(Above, a view of a Aboriginal community in Queensland, Australia.)Despite the fact blood was dripping and forming a small pool on the floor this girl did not seem too fazed. Even as the tiny lake of blood was clotting she was more interested in what I was doing as I weighed a baby.
I called over to the health care worker to elevate the leg, put a pad on and apply some pressure to the wound.
Within a minute or two I could have a look at the wound. Not too bad but would need some sutures. I told the girl and she shrugged and said 'OK.' After contacting her mum I prepared my equipment.
The girl was curious as to what was occurring. Most people become quite squeamish looking at needles that will soon be sticking in them. The injections into the wound can be quite painful.
Most of the aboriginal kids are fairly quiet in the clinic. Often you know they are more boisterous outside. On the way to the shop I often encounter small groups or big packs of them and they seem more comfortable talking away from the clinic. Fair enough really, the clinic usually means pain. Outside is their domain.
As I prepare my sterile field, pour out various solutions and syringe up some lignocaine I ask the girl about school. She tells me the classes she likes ( most of them ) and the ones she is not too keen on (maths).
I ask if she plans to keep going with the studies when she is 16. I am thrilled to learn she is wanting to continue her education. If anything can help with improving the lives of aboriginal people education is definitely one of them.
We discuss the various options and how to gain assistance, both financially and peer support. Most of the kids respond to the question, 'What do you want to do after school?' with a blank look or they want to be a sports star, some want to be mechanics or occasionally a teacher. I don't recall any saying they want to be a nurse ( commonly known as 'sister', never mind if you are male or female).
I am a little shocked when she tells me she wants to be a lawyer. It is the first time I have heard an aboriginal kid express law as an interest. I am thrilled and try to offer some support. The usual stuff like , 'good on you.' 'Keep up your studies' and 'talk to your teachers about improving your chances to be accepted for law.' She nods and smiles. She is way ahead of me. Wheels are in motion.
As I am suturing the wound she tells me about her brothers, her friends, teachers, music she likes, etc etc etc. She is a real chatterbox and it is lovely to hear.
She is so positive. It is a real breath of fresh air. A little part of me wants to think with more girls like this the future of indigenous people can improve.
Before she leaves I provide the usual information relevant to sutures and wound care. Her friends come into the clinic now all the needles and 'yucky' bits have been covered.
I ask her why she wants to do law. With a flat deadpan manner she responds, as if it is the most normal reason in the world,
'So I can get my dad out of prison.'
I called over to the health care worker to elevate the leg, put a pad on and apply some pressure to the wound.
Within a minute or two I could have a look at the wound. Not too bad but would need some sutures. I told the girl and she shrugged and said 'OK.' After contacting her mum I prepared my equipment.
The girl was curious as to what was occurring. Most people become quite squeamish looking at needles that will soon be sticking in them. The injections into the wound can be quite painful.
Most of the aboriginal kids are fairly quiet in the clinic. Often you know they are more boisterous outside. On the way to the shop I often encounter small groups or big packs of them and they seem more comfortable talking away from the clinic. Fair enough really, the clinic usually means pain. Outside is their domain.
As I prepare my sterile field, pour out various solutions and syringe up some lignocaine I ask the girl about school. She tells me the classes she likes ( most of them ) and the ones she is not too keen on (maths).
I ask if she plans to keep going with the studies when she is 16. I am thrilled to learn she is wanting to continue her education. If anything can help with improving the lives of aboriginal people education is definitely one of them.
We discuss the various options and how to gain assistance, both financially and peer support. Most of the kids respond to the question, 'What do you want to do after school?' with a blank look or they want to be a sports star, some want to be mechanics or occasionally a teacher. I don't recall any saying they want to be a nurse ( commonly known as 'sister', never mind if you are male or female).
I am a little shocked when she tells me she wants to be a lawyer. It is the first time I have heard an aboriginal kid express law as an interest. I am thrilled and try to offer some support. The usual stuff like , 'good on you.' 'Keep up your studies' and 'talk to your teachers about improving your chances to be accepted for law.' She nods and smiles. She is way ahead of me. Wheels are in motion.
As I am suturing the wound she tells me about her brothers, her friends, teachers, music she likes, etc etc etc. She is a real chatterbox and it is lovely to hear.
She is so positive. It is a real breath of fresh air. A little part of me wants to think with more girls like this the future of indigenous people can improve.
Before she leaves I provide the usual information relevant to sutures and wound care. Her friends come into the clinic now all the needles and 'yucky' bits have been covered.
I ask her why she wants to do law. With a flat deadpan manner she responds, as if it is the most normal reason in the world,
'So I can get my dad out of prison.'
Monday, August 4, 2008
Definition
Why 'isolated.' It is from the title of an extra qualification a nurse can undertake in Queensland, Australia. It takes about a year and enables the nurse to administer and supply certain medications without having a prescription from a doctor.
The isolated aspect also includes areas where the nurse can supply these medications. Usually they are a long way from any major town and most are small aboriginal communities.
The size of the community range from a few hundred to up to four thousand.
Other skills include intubation, IV access, skills associated with advanced life support, and the drugs include morphine, IV diazepam, anti-biotics and medications associated with heart and breathing emergencies.
Often the nurse in these communities may have limited help from local heath workers. As the only fully trained person they may need to deliver babies, be able to assess and treat STIs, suture wounds and plan health promotion activities. Immunisation is a key part of this with frequent baby checks.
This is post number 1. I will publish this and get back later with some real stories. All the events will be true but no real names will be used and the locations may be altered so nobody can identify any details.
The isolated aspect also includes areas where the nurse can supply these medications. Usually they are a long way from any major town and most are small aboriginal communities.
The size of the community range from a few hundred to up to four thousand.
Other skills include intubation, IV access, skills associated with advanced life support, and the drugs include morphine, IV diazepam, anti-biotics and medications associated with heart and breathing emergencies.
Often the nurse in these communities may have limited help from local heath workers. As the only fully trained person they may need to deliver babies, be able to assess and treat STIs, suture wounds and plan health promotion activities. Immunisation is a key part of this with frequent baby checks.
This is post number 1. I will publish this and get back later with some real stories. All the events will be true but no real names will be used and the locations may be altered so nobody can identify any details.
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