Examplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 129 - 130
Article Text
Caring in a multicultural society
This is an incident that occurred in a hospital where I take my students for their clinical experience. Mrs B, a seventy year old Italian woman lives alone in a flat in Perth and has a son who lives in a town which is in the far north of the state. Mrs B has many friends, many of whom are Australians. One of her friends takes her out shopping every week. She also has a few Italian friends who speak very little English. Mrs B was admitted to the cardiovascular ward with leg ulcers. The contact addresses on her admission notes were those of her son, who was her next of kin, and that of a friend who had specifically mentioned that she did not know any Italian. For a few days everything seemed alright. Mrs B's leg ulcers were being treated. A week later, the doctors scheduled her for an angiogram.
After the angiogram, Mrs B's condition went from bad to worse. She was shouting out something and no-one understood what she meant. She refused food, she would not take any medications and her condition deteriorated. She reverted back to talking in Italian and would not answer in anything but Italian. No-one on the ward could understand what she meant. She just shouted and shouted until she fell asleep. Gradually the ward staff left her alone. Several attempts were made to use the Interpreter Service, but this was not successful because of the hospital bureaucracy. When the interpreter did arrive she came to know that Mrs B was shouting out in pain. It was also revealed that Mrs B thought she was going to die and called out for the people she wanted to see for the last time, particularly her son. The staff were then able to deal with at least some of her problems and Mrs B was much more comfortable. With the help of the interpreter, the student who was looking after Mrs B put up a list of words that she used and their English meaning. There was also a list of the things she liked and disliked.
Because of the efforts of the student and some of the staff on the ward, Mrs B was much happier and her condition improved in a few days.
Selma Alliex RN MSc
Reflection on care
I often wonder why time has not resolved for me some of the tragic client situations I have been involved with during my past practice in acute care settings. I can still remember almost precise details, clients and incidents, mostly of a tragic nature, from as long as twenty-four years ago when I was a third year student nurse and in particular, from my time as a critical care nurse. One of these incidents haunts me more than most. It often occurs at times when there seems to be no related trigger I can associate with the incident, but I think about what has stimulated the recollections. I am quite certain however, that remembering these tragic incidents relates in some way to my inadequate preparation to provide the necessary specific care. Joe was a stereotypical, tattooed 19- year-old 'bikie' and was admitted to the Intensive Care Unit (ICU) following a motor cycle accident. The injuries he received were somewhat unusual as he had sustained the most serious of them from sliding back-first along a corrugated iron fence. His injuries would not normally have warranted his admission to ICU as he was not compromised by either respiratory or cardiac output failure, nor did he have a head injury. The wound on his back was however, so deep and long that it exposed a large proportion of his lumbar and thoracic spine. It was considered that Joe needed to be assessed for neurological impairment. Other injuries included a compound fracture of the radius and ulna and sundry soft tissue injuries.
Providing care for Joe was somewhat different than for most of the clients in ICU, mainly due to the fact that he was neither intubated nor had he sustained a head injury. This meant that the usual one-way conversations undertaken with clients in ICU would instead be met with questions and replies. It was envisaged that Joe's assessment would take no longer than 24 hours and he would then be transferred to the spinal injuries ward or to an acute care setting. It soon became clear that this was not going to be the case. Joe's vital signs began to indicate that he was developing septicaemia. The subsequent results from a battery of tests indicated he was going to be staying with us for a long time, as his wrist injuries were infected by gas gangrene. Because of the depth and extent of the soft tissue injury to his back and the likelihood of the infection spreading, the decision was made to immediately amputate the lower part of Joe's arm.
Over the ensuing weeks, Joe's condition deteriorated. Unfortunately, his back wound became severely infected (not with gas gangrene) resulting in copious discharge which required two nursing staff to constantly pack the wound using four vaginal packs. It also became clear that the gas gangrene was not eliminated from Joe's arm and a further amputation was required. Providing caring for Joe was constant, frustrating, physically difficult and mentally draining. This extended from managing wounds to providing general physical requirements, particularly pressure area care as he could not be placed on his back or right side and didn't like lying prone. Pain management was also a constant challenge and through all of this, not surprisingly, Joe was demanding and uncooperative. The stress of caring for him soon began to show among the nursing staff and complaints arose if any of us were assigned to look after him for more than three shifts in a row. The medical staff were often questioned as to whether Joe should be intubated, but his respiratory assessment didn't indicate the necessity.
Over the weeks, Joe's arm wound didn't respond to treatment and the gas gangrene still had a hold. It soon became apparent that he could die from the gas gangrene infection if it could not be stopped. The decision was then made to remove a much larger section of Joe's arm. I came on a late shift one afternoon and was allocated to care for Joe who was about to come back from the operating theatre. He was brought back to ICU still intubated. I can remember feeling guilty at the time, at the relief I felt about not having to face Joe straight away. I could get on with the myriad of tasks that needed to be done, free from the face-to-face emotional tension that had built up between us over the weeks. The post-operative handover was uneventful.
I knew that Joe's operation had been to amputate more of his arm but I was not prepared for what was known as a 'forequarter'. I looked at the bandages and the lack of a shoulder and for the first time at Joe peacefully sleeping (although intubated) and my stomach churned. 'How was he ever going to get through all of this?' I just felt like disappearing. However, the time for reflection didn't last long. Joe's blood pressure began the usual post-operative response as the anaesthetic started to wear off. As Joe's anaesthetic became lighter, he began to fight the respirator and at the same time, he began to bleed profusely from the wound. All hell let loose as blood and fluids were pumped into Joe. He woke up and started to strain on his intubation tube, forcing just enough air past the cuff to strain the words at an hysterical pitch 'Am I going to die?' 'Am I going to die?' I could not look at his eyes, although I instinctively knew their portrayal of torment. I just kept saying, 'We are doing all we can'. The bleeding could not be abated and Joe died.
I have several beliefs about why Joe's story has become my baggage. Mostly it relates to the fundamental question of 'What is care?'. For Joe to have any chance of surviving, he needed all the constant treatments we inflicted on him but contrary to this, I wonder if in providing this care, we were not also torturing him? Irrespective of obligatory rest periods, he was touched, prodded and probed nearly every minute of the night and day.
Coupled with this, he must have felt he had no control over what was going on around him, and in reality he didn't. In these circumstances perhaps he couldn't. For myself, I still have a nagging belief that I should have been able to provide him with emotional and spiritual solace and could not.
Susan Tregoning RN MEd Admin
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