Look Closer

What do you see, nurses, what do you see?

Are you thinking when you are looking at me,

A crabbit old woman, not very wise,

Uncertain of habit, with far-away eyes,

Who dribbles her food and makes no reply,

When you say in a loud voice, “I do wish you’d try”,

Who seems not to notice the things that you do,

And forever is losing a stocking or shoe,

Who, quite unresisting, lets you do as you will,

With bathing and feeding, the long day to fill?

Is that what you’re thinking, is that what you see?

Then open your eyes, you’re not looking at me,

I’ll tell you who I am as I sit here so still,

As I move at your bidding, as I eat at your will,

I’m a small child of ten with a father and mother,

Brothers and sisters, who love one another,

A young girl of sixteen with wings on her feet,

Dreaming that soon a true lover she’ll meet;

A bride now at twenty – my heart gives a leap,

Remembering the vows that I promised to keep;

At twenty-five now I have young of my own,

Who need me to build a secure, happy home;

A woman of thirty, my young now grow fast,

Bound to each other with ties that should last;

At forty my young sons will soon all be gone,

But my man stays beside me to see I don’t mourn;

At fifty once more babies play round my knee,

Again we know children, my loved one and me.

~

Dark days are upon me, my husband is dead,

I look at the future, I shudder with dread,

For my young are all busy with young of their own,

And I think of the years and the love that I’ve known,

I’m an old woman now and nature is cruel,

‘Tis her jest to make old age look like a fool.

The body it crumbles, grace and vigour depart,

There is a stone where I once had a heart.

But inside this old carcase a young girl still dwells,

And now and again my battered heart swells.

I remember the joys, I remember the pain,

And I’m loving and living life over again.

~

I think of the years all too few – gone too fast,

And accept the stark fact that nothing can last.

So open your eyes, nurses, open and see,

Not a crabbit old woman, look closer –see ME.

Phyllis McCormack

~

~Act Twenty Nine~

  • At 5pm the nurses notes read:

Signed by the Staff Nurse who had given mum the Vancomycin.

(Attended at 16.05).   17.00 Patient returned from X-Ray following Doppler.

On return at 17.00 patient was Almost Unresponsive.

Pulse 88.

B.P. 113/76.

O2 Sats 24%.

No Charts were written for the above!

+Trauma mask commenced.

O2 Sats improved to 92%.

Medical Staff informed.

Blood gases taken.

Furosemide 40mg given IV (given at 17.10 prescribed by the emergency doctor).

N.B. My mother at 11.10am had tolerated O2 continuously at 4.L.

Yet when she was taken to the Doppler she was not on O2?

  • Mum had been at the Doppler for 1 Hour. (This should take approximateley 15 minutes.)?
  • A doctor was urgently called in from another ward .

ATSP re. low Sats. + very unwell.

Returned from X-Ray department – clammy + low responsiveness  low Sats.

87 female – cognitive impairment.

COPD.

LVH.

Elevated B.P.

Epilepsy*

(*Taken from FY2’s Admission Document, which misled the Consultant and started all of this downward spiral). (Also this *was from a stroke years before!)

Admitted 31.1… – LRTI – not improved despite IV Augmentin and IV Ceftriaxone.

  • Why no mention of all the other drugs, especially the *IV Vancomycin given one hour before this emergency doctor’s arrival; *which was written on page One of the prescriptions instead of the current page Four; and given Before the Doppler?  Therefore once again another doctor only read the previous notes, as the prescriptions would have shown the rest including the Vancomycin, and having seen this the ‘Blank’ separate form would also have been noticed , hopefully!

Developed Pulmonary Oedema 4.2… (Developed this before the 4th, but FY2 wrote on 4th ‘New Since Admission’ making it appear it happened on the 4th!)

CXR – wedge shaped opacity and Dalteparin started.  (Started on 4th and Taken from doctors notes/prescription)

  • Where are the other notes with regard to Heparin etc. stopped and started?

Doppler US legs today confirmed DVT and likely PE’s?

O/E  B.P. 120/67, p 110,  Sats. 80% initially  T  ?

  • The emergency doctor would be unaware that the nurses notes stated: as there was No Chart written for 5pm B.P 113/76, pulse 88, O2 Sats 24% Off Oxygen.
  • Where does 80% initially come from as they were 24% at 5pm, then improved after the trauma mask commenced, to 92%.

-> 92% on 15L* O2, B.M 9.8.

  • The staff nurse must have Verbalised the 15L ->*

Chest RR 28down A/E bibasally

harsh breath sounds (L) base.

CVS  Hs1 +11 + 0

mild pitting oedema

JVP

GCS – e3/m5/v4 12/15

ECG SR ? (cannot read writing!)

ABG pm 15L O2

  • The following Arterial Results noted by the SHO111 were  Analyzed by FY2 @ 17.03!
  • Why was FY2 analyzing this sample with the Results @ 17.03 when mum had been wheeled back into the ward @ 17.00?
  • How was it possible to take bloods in the ward after 17.00 and have the analyzed Results @ 17.03 from the Lab?
  • Why the Delay when mum was almost unresponsive @ 24% oxygen when wheeled back to the ward?
  • Why was she wheeled back to the ward without any Oxygen?
  • Why if FY2 took this sample during the Doppler did she not accompany her patient back to the ward?
  • Why did FY2 not give any O2?
  • What was FY2 doing at the Doppler in the first place when she was Not On Duty?
  • Why did FY2 analyze this Arterial blood?
  • What happened at that Doppler?
  • Especially, given the fact that a procedure which normally takes 15minutes, took mum from 4pm until 5pm?
  • Why was mum at the Doppler for an Hour?

He 56.8

pCO2 9.4

pO2 8.3

BE 20

Bic 31.1

  • Why did the SHO111 not wonder where these Arterial Blood Results had transpired from since she was the doctor called in that emergency?
  • Did she know that FY2 was with mum at the Doppler?
  • Even if FY2 had been nearby and been called by the X-ray department to an emergency and she took bloods to see what was happening, this would not excuse her for not giving her patient oxygen at the very least! 
  • This would also not excuse No Notes written as a report!

Imp 1) DVT + likely PE’s?

11) LRTI not especially ? abx.

111) degree of pulmonary oedema.

Plan: 5.05pm

IV Furosemide

Paracetamol cal.

IV Vancomycin * 

  • ( This * was already given, therefore did the SHO111 Plan this for the next 48hrs?)
  • This SHO111 copied prescriptions and notes, already written by FY2 before the 7th.  
  • Did she not notice the ‘Special Instructions for Vancomycin which had been ignored as there were No Doctors Notes written that day prior to her own?

MRSA Screen

  • Staphylococcus aureaus (MRSA) is a gram positive bacteria that causes a variety of infections including pneumonia.  This gram positive bacteria becomes pathogenic when there is damage or injury to the skin, giving bacteria systemic access to the organs and tissues.  Those most at risk include individuals with a weakened immune system.
  • Look at the numerous injections in mum’s stomach and wrists and hands!
  • Elastic stockings never entered into the frame!

LET Next-of Kin know of deterioration.

If this SHO111 had not written this would I have been told at all until too late?

I Do Not believe I would have been called without this SHO111 instruction to do so!

N.B. ~This  SHO111 in her professional capacity wrote:

5.05pm PLAN:

IV Vancomycin   (which she took from the prescription written by FY2 )

  • Why did SHO111 Not Observe that this had already been given by the Staff Nurse and therefore conclude that since mum was at the Doppler from 4-5pm, that she was given this Before the Doppler and at a far too fast rate which was extremely dangerous? 

Plus Not Given over 120 minutes!

  • At 5.10 mum was given:

40mg Furosemide IV

  • The ward manager who had telephoned me to come in, and who had expected that I had gone visiting a former patient, wrote her report of almost three pages about Me at 5pm, at precisely the same time of 5pm that my mother returned to the ward ‘Almost Unresponsive’.
  • At 6.30pm Nurses notes: 

(The same nurse who gave the Vancomycin).

  • N.B. There is no mention in these nurses notes about the 1000mg Vancomycin she had given despite initialing them as given.  Not even IV as recorded!

Radiographer attended for X-ray patient’s chest, patient’s daughter refused to have this carried out.

medical staff informed.

  • At 7.30 the SHO-On-Call wrote my reasons for this as you will read below*.
  • The emergency SHO111 took an Arterial sample which was analyzed @ 18.48.

Results:

cH            47.7up

pCO2       10.4up.up

pO2          10down

Na+          146up

K+            4.3

Cl              103

Ca++       1.19

Hct          42

Glu          9.4up

Lac          1.4

tHb          12.8

O2Hb      82.8down

COHb      1.8up

MetHb    1.0down

HHb        4.5

sO2          95.4

BE(B)      10.9

HCO3(c) 40.2up.up

Biochemistry Results:

*Collected  17.01.

*Received 18.56.

*Report Issued on the 8th at 09.26!

Sodium *146

Potassium 4.3

Chloride 99

Urea *12.4

Creatinine 85

eGFR>60

Glucose *8.2   What caused the rise in this from 10am until 5.01?

CRP *461

Bilirubin 6

AST *53

ALT *210

GAMMA-GT *551

Alk. Phos *442

Protein 62

Albumin *21

Globulins *41

They were Collected at *17.01 but

Not Received until 18.56. 

Why the delay?

 *A Further Overdose

  • At 7pm mum was given:

*1G Paracetamol IV given

Nebulizers given

Attempted to reduce O2 therapy and give humidified O2 but saturation dropped to 84%.

Re-commenced on trauma mask at 10L.

*Another doubling up of Paracetamol from the previous dose before 4pm!

7.10pm Temperature 38.2!

7.10pm

The 40mg Furosemide IV was also given (written on the SHO111 Plan at 5.05pm).

  • 7.30 SH-On-Call:

Above handed over – background noted – discussed patient’s condition with daughter.

Concern how unwell she is -clearly very upset with condition/situation.  Feels that condition much worse by treatment in hospital.

“Never should have made her come in!”

Explained that we are treating a combination of problems – infection/possible PTE/possible LVF (Lower Ventricular Hypertrophy).

Understands that we feel that if Mrs……condition does not respond to treatment, that there are no other interventions that we think would be appropriate.

Agrees that should ? Rx but that Mrs…..should not be for resucitation in the event of a cardio-respiratory arrest…..

By now every instinct in me knew that if mum had to go through this sort of trauma she could have been in agony if they had to revive her from a collapse, as I did not feel her frail little frame could take a pounding.

I beat myself up about agreeing to this for years until  discovered the amount of poisons being given to her and exactly what this FY2 had done from the beginning!

Nevertheless I still feel that I was made a party to ending this needless torture because that is what it was – Needless!

Not only was I responsible for talking her into going there; at the behest of that G.P. about her heart of all things; but I was party to ‘pulling the plug on my own mother’ albeit extremely reluctantly, and only because of the condition she had now been reduced to!

Note:*

Patient’s daughter initially not keen for CXR-moving patient about too much.

Now having explained this further she is happy for this to go ahead, therefore reason for delay…….. was that she would have this in her bed, with little movement……….Patient on 10L O2 SPO2-90% SPO2 quickly downward off O2 between changing masks.

Chest reviewed- some wheeze in addition to ? creps at base without nebs.  Patient flushed, feels warm, mouth dry.

Great!

Report ABG on 10L.. PO2 10.0, PCO2 10.4 up, cH 47.7 up, HCO3 40.2 up, ->???

These were all taken from the Arterial Sample Results at 6.48pm.

(P) ? current Rx – change to humidified O2. try to reduce further but need to maintain SPO2.

-IV Paracetamol (given at 7pm).

CXR reg. nebs.

Review later.

Not for resusitation in the course of cardiac arrest.

I wonder if the ward manager read this as she Did Not write in her own notes from the ‘meeting’ at that time I wanted mum to be resusitated?

7.2…..

Note patient better ? nebs – SPO2 95% on 8L.

Awaiting CXR  (Attended 7.26).

Daughter to stay in with patient overnight if possible.

Will speak to medical staff?  SHO11.

CXR Results: 7.2…..

*This report has mum at 89 instead of 87 and while this may appear a trifle incidental it illustrates a further example of the carelessness in the NHS.

There was an ECG report with another persons name on plus another nutrition sheet with someone else’s name scored through and mum’s written above!

There are other charts wrongly completed, such as SIPS of fluid on the 8th when mum was in a Coma!

*There is now very extensive consolidation involving the right hemothorax together with a small amount of pleural fluid in keeping with severe infection.

7.2…..

CXR Reviewed:

Patchy opacification of whole of (R) lung.

Ab? bibasal effusion.

Most likely cause – infection -??aspiration???  Despite SALT Report?

Note patient’s daughter concerned re. LMWH Rx given patients previous history of intracerebrael haemorrhage in 200..?

*Please discuss more.

*No Discussion about this Ever Took Place!

  • N.B. The same staff nurse who gave the Vancomycin, and was at the ‘meeting’ was nowhere to be seen; when I arrived after the phone call from the ward manager who wrote her three pages of notes on Me at 5pm then left before I arrived;  and had written nurses notes at 3.20pm, 5pm, 6.20pm and 7.10pm (as according to the ward manager she was on back shift!)
  • Therefore this staff nurse was writing her notes at 5pm about my mother, at the same time that the ward manager was writing her notes about ME, so who was with my mother until the emergency doctor arrived at 5.05pm?

Yet No Charts were completed after 12.00 for B.P., pulse.

The 24% should have been written etc.

These Charts would show the effects which erupted from the Vancomycin IV which this staff nurse had given mum.

*Can Vancomycin hydrochloride cause Hyperclycaemia?

*Age of people who have Hyperglycaemia when taking Vancomycin hydrochloride.

0-1       =    6.67%.

2-29    =   0.00%.

30-49 =   6.67.

60 +    = 66.67%.

Top co-used drugs for these people include Prednisolone, Furosemide, Corticosteroids, Salbutamol and Ipratropium All of which can cause Hyperglycaemia (High Blood Sugar)!

N.B. This only flagged up after the 5.03 Arterial Blood Sample showed elevated Glucose!

Conversely, Clarithromycin can cause Hypoglycaemia (Low Blood Sugar).

Great, isn’t it?  If you manage to survive it all That Is!

On September 4th 2012 a post-marketing study showed that 2,158 people reported to have side effects when taking Vancomycin hydrochloride.

Common side effects of hydrochloride include fever, sepsis, hypotension, renal failure acute condition.

  • The Department of Haematology Results:
  • Date of Sample 07.02….@ 19/..?
  • Date of Report 07.02…@  20/..?
  • *05.02…  FBC.  No Clinical Details Provided.
  • PLEASE SUPPLY RELEVANT CLINICAL DETAILS.

WBC 24.27

Hb 13.0

Plts 357

WOW!

  • At 10-12pm mum was given:

1G Paracetamol IV

  • At 11pm another nurse wrote:

……..remains fairly settled in upright position.

O2 therapy continues and has been around 90-92%.

IV Antibiotics as charted.       Which? When?

Daughter present.

….has been talking at times.

This was misinterpreted as mum had opened her eyes and looked at me and I said to her  “Hi, Young One”.   She closed her eyes again!

1am. Required an increase in her O2 to 10L. to lifting her O2 up from 83-94% and has remained at that level.

Urinary volumes were 12% at 2am.

More settled, breathing less laboured with the O2 improvement.

6a.m.. Required again -O2 still around 95%.

But 4% urinary output much less at this time.

Positional change -other (R) side, skin slightly red.

IV Antibiotics and IV Paracetamol as charted.    Which ones?

Temp. now settled.

More settled now.

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