Life and Death Episode 2 - The Heartbreaking Deterioration

Hello and Welcome to Episode 2 of Life and Death.  This week's episode features one of the more heartbreaking cases I was involved in as a student nurse.  A rough experience not going to lie, but all our experiences - whether we're students, mentors, qualified or specialist professionals contribute to the clinician we ultimately become.

This case certainly helped my development and I hope to pass some of this on to current students, qualified staff or people of all ages considering a future in healthcare.

What Happened?

To start the story, I'll briefly mention that I was just at the halfway point of my training and at the stage where I was being given 2 or 3 patients to look after just to get a feel for what kind of responsibilities, tasks and patient care would need to be provided.

*Important! If you are a second year student or above reading this, I actively encourage you to take on the responsibility of a couple of patients when you are on placement.  A nurse will always be around to support and it will make you so much more prepared for second and third year placements.*

One of my 3 patients had been discharged and therefore an empty bed became available.  I took handover from A&E for a patient that was deemed suitable for that bed.

*Important! Get familiar with giving and receiving handovers.  It is not something that is taught well at university but plays a vital part in patient care.  Read up on the SBAR style of handover and practice giving / receiving handover.*

The patient was received from A&E and placed into the care of myself with the registered nurse overseeing.  However, on initial assessment... things were not as they seemed.  Compared to the observations in A&E, on arrival to my care, this patient had a drop in blood pressure significant enough to make the patient clinically extremely unwell.  This was escalated to the nurse overseeing me and the doctors.

*Important!  If a patient scores 5 or higher on the NEWS Chart, or has observations out of range you MUST ESCALATE this to somebody.  So many students take observations and do not tell anyone if there is anything is out of range.  This puts patients at risk!*

The nurse overseeing me was putting bolas fluids through this patient as this was outside my scope of practice - Bolas meaning X amount of fluid (Anywhere between 250mls and 1000mls normally) As fast as possible into this patient.  Meanwhile the team of doctors were on hand reviewing this patient.

Prior to arrival, this patient had a CT scan which initially showed a bowel obstruction.  The patient was also catheterized in A&E.  As well as the Blood Pressure staying low despite the amount of IV Fluids being administered, urine output was really poor.  At first, we were all a bit unsure why this was happening.

I decided to look in this patient's notes to see if I was missing anything and a senior doctor reviewed the scans.  The senior doctor came to the conclusion that this patient had an Aortic Dissection - A tear in the wall of the aorta.  This explained why there was the issue of low blood pressure.  As I was looking through the notes, I came across the past medical history... It was at this point when the heartbreak set in.

This was not handed over - possibly because staff down there were not aware of the significance of this condition.  But this patient in their past medical history in their notes was said to have Ehler's-Danlos Syndrome --> A connective tissue disorder.  As this patient was believed to have a tear in the aortic wall, it was reading this past medical history that made me realise that the prospects for this patient were not good at all.

How did I feel?

Understandably, gutted.  When you realise that it does not matter how much treatment, care, drugs, fluids etc. you can give, a patient will just simply not survive, you just get a sense of hopelessness initially because you know that this is not preventable.

Ultimately, What happens?

You get a sense of purpose and desire as well.  Not everyone will make it out of hospital.  Unfortunately, death is part of life and you get this motivation that you have to do whatever you can to make that individual as comfortable as possible.

Therefore, I spoke to the palliative care team.  The palliative care team are the best people to contact when patients have a poor prognosis due to their presenting condition.  The palliative care team can prescribe something called the anticipatory medications bundle.  These are medications normally given subcutaneously to assist with pain, agitation, nausea / vomiting etc.

*Important! Symptom Management is the highest priority for the patient when they are deemed to be end of life.  You must make sure that a dying patient is not suffering.  Comfort observations (Only manual pulse and respiratory rate) are normally performed.  Elevated pulse or respiration rate indicates the patient is in discomfort.*

Not only do you take the patient into consideration, you have to make sure that person's family is taken care of as well.  Seeing a relative go downhill and pass away is a very distressing time for that individual's family.  Ultimately, this patient did pass away under my care and while it was a really sad moment for everyone involved.  I could take that bit of pride that I did the best I could for that patient and their family.  Despite what happened, the family were so lovely and appreciative of everything that was done by everyone on shift that day - it just was not meant to be.

Things to Take Away:

1. Don't be scared to have patients under your responsibility as a student.  There will always be someone around to help.

2. Escalate any observations out of range or anything that does not sit right with you.

3. Practice giving and receiving handovers.  Ask if you are unsure.

4. Unfortunately, not all patients have a good prognosis.

5. Seek help and advice from specialist teams (such as palliative in this case)

6. Prioritise comfort for the end of life patient so they can pass away with dignity.

7. Please make sure a patient's family who are in distressing situations are taken care of.

That's all for this week.  See you guys soon.