IF

  • IF You can keep your head while all about you

are losing theirs and blaming it on you,

If you can trust yourself when all men doubt you,

But make allowance for their doubting too,

If you can wait and not be tired by waiting,

Or being lied about, don’t deal in lies,

Or being hated don’t give way to hating,

And yet don’t look too good, or talk too wise.

  • IF You can dream-and not make dreams your master,

If you can think-and not make thoughts your aim,

If you can meet with Triumph and Disaster,

And treat those two imposters just the same,

If you can bear to hear the truth you’ve spoken,

Twisted by knaves to make a trap for fools,

Or watch the things you gave your life to broken,

And stoop and build’em up with worn-out tools.

  • IF you can make one heap of all your winnings,

And risk it on one turn of pitch-and-toss,

And lose, and start again at your beginnings,

And never breathe a word about your loss,

If you can force your heart and nerve and sinew,

To serve your turn long after they are gone,

And so hold on when there is nothing in you,

Except the will which says to them ‘Hold on’.

  • IF you can talk with crowds and keep your virtue,

Or walk with Kings-nor lose the common touch,

If neither foes nor loving friends can hurt you,

If all men count with you, but none too much,

If you can fill the unforgiving minute,

With sixty seconds’ worth of distance run,

Yours is the Earth and everything in it,

And-which is more-you’ll be a man my son!

Rudyard Kipling

~Act Twenty Seven~

  • ~ Part 1 of this Act ended with~

‘She Did Not mention the fact that my mother was being taken for a Doppler while I was wasting my time with her!’

‘The fact was that this ‘meeting’ lasted from 20 minutes to four until 15 minutes to five!’

Not Once, was there mention of my mother being taken for a ‘Doppler’ test – while we were having this conversation!

During visiting hours?

Presumably another nurse did not take mum for a Doppler without the Ward Manager’s knowledge therefore why did she not mention to me that mum was going for this at 4 o’clock?

Why did the Ward Manager tell me that mum was going to be weighed at 4 o’clock?  After all, she had consulted her notes before stating this therefore she must have known about the Doppler as she was in Full Charge of that ward!

Did FY2 know that mum was going to the Doppler at 4 o’clock?

Who knew and When did they know?

Why was mum at the Doppler for almost One Hour?

In fact, I hurried out of that room back to mum to give her the banana and ricicles; which had been delayed due to the milk which I had brought with me turning sour and had to be bought afresh in the local shop nearby; and my friend had gone to buy this.

It was in that shop that FY2was seen yet was Not on Duty That Day?

  • Mum never received her food that day, and never received any food ever again!
  • Mum and I never spoke to each other again!

I almost fainted as her bed was completely empty!

I was informed that she had been taken for a Doppler at 4 o’clock.

I waited until 10 minutes to five feeling guilty about staying after visiting hours, thinking the other patients may soon be having their dinner or being attended to by nurses?

My friend mentioned that we were going to visit a previous patient ( one who had witnessed my mother’s extremely bad night from the 3rd/4th!).

I reluctantly left to go back home, in order to return after eating, and was just in the house when the phone rang between 5pm and 5.30pm!

This was to tell me that mum had returned from the ‘Doppler’ in a bad way!

  • Remember, mum was waiting for fresh milk to eat her ricicles before that meeting!

This ward manager also said in a very bold and aggressively challenging voice, (which was the entire opposite of her attitude from her notes which sound so accommodating)

‘I thought you were going visiting!’

‘Not Me!’ 

  • Did she actually think I would not be in to take this call?

We turned around and flew out the door again, but the traffic at tea-time was terrible for a short journey normally by car.

I ran into that ward to find mum with a face like a balloon, and she just stared constantly into my eyes as if trying to tell me what was happening to her.

I knew in an instant!

The Anaphylactoid Symptoms were plain to see even for a fool, and mum looked absolutely alarmed.

I took off my coat and sat down and not All the Hounds of Hell itself Would Have Moved Me from Mum’s Side!

The ward manager had Gone Home!

The staff nurse who had been at the meeting was nowhere to be seen?

  • The details of the Doppler report was:

Attended 07/02/.. 16.15pm.

US LEG:

*Suboptimal limited examination due to patient condition.*

Was there an initial proposal for some other type of examination?

  • N.B. My mother was fine if not doped before I went in for this talk.
  • Why was she in this *Condition when she Arrived at the Doppler?*
  • Who booked the Doppler for 4pm visiting hours on the 7th?
  • The Consultant instructed this to the ward manager on the 5th, therefore she must have booked this, yet she told me at the meeting that she was going to weigh my mother at 4pm on the 7th?

*Echogenic matter present in the left common femoral and superficial femoral veins.

Spontaneous venous flow is present in the right common femoral and superficial veins.

IMPRESSION:

Thrombus present in the left leg vein to the level of the left common femoral vein.

  • Now, for the bit to make you sit up and take notice!
  • A word of Warning folks, you will Really need All of your concentration to absorb the following!

~Act Twenty Eight~

On 7th FY2 had written a prescription for 1G Vancomycin IV to be given at 4-6pm.

FY2 wrote this prescription on a ‘blank’ box number ‘D’ which had three other prescriptions dated the 4th, Four Pages Back!

This  box D was initially left ‘blank’ along with another full sheet E,F,G,H by FY2 when she wrote the new sheets on the 4th?  She then completed prescriptions on J,K,L,M,N,P,R.

In not using S which was at the end of the prescription sheet, anyone looking at the current prescriptions would not notice that this 1G Vancomycin IV had been written on D.

Plus the fact that 2G Ceftriaxone IV was also given on the 7th at 7-9am, along with 500mg Clarithromycin IV which was given at 12-2pm, and then the Vancomycin !

Why would anyone want to go back Four pages to a blank space to complete a prescription instead of using the next one in sequence?

This meant that this was being dispensed by the pharmacist BEFORE I went into the meeting.

This meant it had been written at the latest between 3-3.30pm in order for him to dispense it, as he was dispensing when I was there.

This means that FY2 had written this prescription for 1G Vancomycin IV (a drug of last resort) BEFORE mum went to the Doppler!

THE QUESTION ARISES?

  • On the 5th at his previous visit the Consultant had written – continue antibiotics 2 days => review.
  • He would not be in until the 8th therefore would not know about the Vancomycin given on the 7th until it had Been Given!

Do you think he would have been aware of the fact that the Vancomycin had been given far too quickly?

It’s not difficult to see where Major Problems can arise when the ‘Main Man’ is not in the picture!

  • There were No Doctors Notes written on the 6th.
  • FY2 was Not On Duty on the 6th.

Now here is a strange thing:

  • When I telephoned the Nutritional Support Sister on the 6th, she contacted the ward sister, dietitian, and another ward sister Plus FY2? yet she was Not On Duty that day, in fact no-one was?
  • There were No Doctors Notes written on the 7th.
  • FY2 was Not On Duty on the 7th.
  • When did FY2 write this,  (I had asked to speak to the ‘doctor’ and was told she was not available that day) as she was only seen in the local shop and was Not On Duty in the ward that day?
  • Even if she had been in the ward that morning, Why were there No Doctors Notes regarding such an important change in Drugs etc.
  • FY2 decided to give this extremely potent drug of last resort without consulting any other Senior doctor or the Consultant!

How do I know this?

Because she always wrote any other doctor’s instructions in her notes!

It helped to fill in blank pages, didn’t it?

  • As she had written this prescription in time for the pharmacist to dispense it early afternoon, Why did FY2 write it Before mum took badly at the Doppler?
  • Ah, but wait until you hear about the Doppler and FY2!
  • The next day of the 8th FY2 told me that there was nothing more they could do for mum and that she was giving her a drug of ‘Last Resort’, which was this Vancomycin (which mum had Already Been Given on the 7th which precipitated her Dying on the 8th!). There was No mention that it had been given Before the Doppler on the 7th and that it had been given far too quickly!
  • Once again, FY2 implied that this was to be given to mum that day, with no mention that it had already been given the day before!  Exactly the same as on the 4th scenario with the Heparin!

This Gets Worse!

  • The pharmacist wrote a separate sheet for this drug called:

ANTIBIOTIC RECORDING CHART

VANCOMYCIN

Please record the administration and sample times below.  his enables samples to be accurately interpreted to avoid treatment failure or toxicity to the patient.

Date: 07/02.

Drug: Vancomycin. Dose: 1000mg. Time of administration or start of infusion. Time infusion complete. Given by. Sample date. Sample time.

Guess What!

The Staff Nurse who was in the meeting with us, GAVE mum this 1G Vancomycin IV and initialled this as given!

 This meant that this drug had been given Before the meeting!

This meant that this drug had been given to mum at ‘A Rate of Noughts‘  Before she went to the Doppler!

A Quick Exit!

The Staff Nurse completely ignored this Antibiotic Recording Chart and left it blank!

Despite the pharmacist writing on the Prescription under:

Additional Instructions/ Comments/Pharmacy:

48 hourly.

Give Over 120 Minutes!

 

  • At 4-6pm mum was given:

1 Paracetamol Calpol

1000mg Vancomycin IV

Conflicting Drugs:

Vancomycin Indications:

Is indicated for the treatment of serious, life-threatening infections by Gram-positive bacteria  (So FY2 finally discovered which bacteria it was?) which are unresponsive to other less toxic antibiotics.  It acts by inhibiting proper cell wall synthesis in Gram-positive bacteria.  Most Gram-positive bacteria are intrinsically resistant to Vancomycin because their outer membrane is impermeable to large glycopeptide molecules.

It is Not active against Gram-negative bacteria.  (So FY2 was certain this was not Gram-negative?)

  • Strange thing is. Where are the results showing the Bacteria?

In particular, Vancomycin should Not be used to treat methillin-sensitive Staphylococcus aureus because it is inferior to penicillins such as nafcillin.

Adverse Effects:

Local pain, which may be severe and/or thrombophlebitis.

Anaphylaxis, Superinfection, Thrombocytopaenia.

It has traditionally been considered a nephrotoxic and ototoxic drug!

Caution in elderly patients!

It should be noted that the total systemic and renal clearance of Vancomycin are reduced in the elderly!

  • IV may cause nausea, take as directed with food, small, frequent meals, frequent mouth care.
  • Report immediately any chills, pain, swelling!

Vancomycin does not readily diffuse across normal meninges into the spinal fluid, but, when the meninges are inflamed, penetration into the spinal fluid occurs!

  • Rapid bolus administration (e.g. Over Several Minutes) may be associated with exaggerated hypotension including shock and rarely, cardiac arrest!

Vancomycin is Ototoxic to the auditory portion of the eight cranial nerve.  This means hearing loss is possible from taking Vancomycin and is more common with I.V.

Mum always had terrific hearing!

Vancomycin IV is processed by the kidney.  Patients with no fluid restrictions should maintain adequate fluid intake to ‘flush’ the kidney and reduce the likelihood of overloading and damaging the organ.

The ward manager had written after 3pm in HUGE writing:

N.B.M – General Condition -very poor

So, that takes care of adequate fluid to ‘flush’ the kidney!

And FY2 knew all of this before giving it to mum?

While on treatment, two kidney markers, BUN and Creatinine, as well as Vancomycin drug levels, are monitored in the blood.  An increase in the levels of these markers correlates with a decline in kidney function, and a reduction in the dose is indicated to restore and preserve kidney function.  Also as kidney function declines, urine output decreases, causing dehydration and increase in thirst.  Nephrotoxicity.

Prescribing Vancomycin in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Side Effects:

Decreased B.P., increased heart rate and flushing, usually when IV is given too fast!

Shortness of breath or difficulty breathing may occur while on Vancomycin IV therapy, especially with the first dose.

What sort of imbecile would put my mother on this?

Acquired microbial resistance to Vancomycin is a growing problem, particularly within ‘health care’  facilities such as hospitals!

Say That Again?

N.B. There is some suspicion that agricultural use of Avoparcin, another similar glycopeptide antibiotic, has contributed to the emergence of Vancomycin-resistant organisms.

Incompatible with:

*Ceftriaxone  2G was given to mum at 7-9am!

*Heparin         7500units given at 12-2pm!

May cause neutropaenia; use caution with Carbamazepine.

*5mls Carbamazepine given at 7-9am!

IV Induced Anaphylaxis has been reported

These signs and symptoms should be assessed immediately (One Hour Late!) and Vancomycin Stopped until hypersensitivity to Vancomycin is excluded as the cause of these symptoms.

  • N.B. There is No Specific Therapy for Overdose with Vancomycin!

Another Drug with No Antidote?

Something very questionable here!

Subsequent reviews of accumulated case reports of Vancomycin-related nephrotoxicity found that many of the patients had also received other known nephrotoxins, particularly aminoglycosides.

Vancomycin can also be given orally, but this method is very expensive!   (Not that mum could have had this as she was now in a Coma!)

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