Discharged At Own Risk

I had my first case of discharged at own risk today. The patient came in for vomiting for investigation sometime after 12 noon. Upon arrival at the ward, the admin staff showed her to the room. Then the in-charge and admin staff quickly arranged for the AXR to be done stat. HCA K sent the patient down for the AXR. As I was busy with my medication rounds, I did not note the exact time of patient's arrival at the ward and return from AXR.

At 1:10pm, the specialist reviewed the patient at the ward, wrote up the IMR and left. Around 1:20pm, I reviewed the IMR and noted the specialist's orders. Domperidone suppository was ordered. As the ward admission interview was not done yet, I did a quick check with the mother on the child's condition. She was carrying the child and walking up-and-down the corridor and talking on her mobile. The mother replied quickly that the child had vomited once before admission, but not since. Then she looked somewhat unhappy to be interrupted and went back to her phone conversation. Seeing that the mother was busy and not wanting to be interrupted on her phone, I explained to the mother that we will not give the child the suppository yet. That was my mistake in my judgement.

Around 2:20pm, the child vomited. The mother called the specialist to complain that we had not done any intervention for her child since her arrival 2 hours ago. At 2:30pm, the specialist called up and instructed me to give the supp Domper stat, which I did immediately. As the shift handover report was in progress in the treatment room, SSN Y who was in-charge in that afternoon instructed that I only call the MO to follow-up with the IV cannulation after the shift handover report was done. When the shift handover report was done around 2:40pm, SSN Y arranged for the IV cannulation to be done by the MO. Meanwhile, the afternoon staff interviewed the patient for ward admission.

At 3pm, before the MO arrived for IV cannulation, the mother came to the nurses' station and demanded to be discharged. I called the specialist for his agreement on the matter, the medication for discharge and his fees. Meanwhile I had a hard time searching for the AOR form, so SSN Y helped me. Although we received the X-ray report via fax, we had not received the X-ray film yet. The admin staff called X-ray department to ask for their delivery of the X-ray film, but their porter was overloaded too. It was around 3:30pm when we received the patient's admissions record (with the patient's ID stickers) from the admissions department. It turned out that the mother only registered her child's hospital admission at around 1:30pm.

We quickly did the billings and documentation labelling for this patient. While we were doing so, the specialist came round for a second visit. SSN Y, as the in-charge, accompanied the specialist for his round. The specialist returned and signed the required IMR and billing papers. Then SSN Y sent the afternoon runner SEN MY down with the relevant documents for the pharmacy and the billing office. According to the specialist, the mother is herself a staff nurse at a restructured hospital. She is also a friend of our ward staff SN J, who was not on-duty today. This is really strange to me, because as an SN herself, she should know the workings of a ward and the priorities of investigations/interventions.

It was almost 3:50pm. The NO returned from her meeting and the admin staff updated her of the AOR discharge. The NO said that from the way the patient's mother was on the phone almost all the time since arrival at the ward, the NO suspected that her claims of a 2 hour delay in intervention was not the main reason for her AOR discharge request. Anyway, the NO went to talk the mother for service recovery. According to the NO, the patient's mother was about to start complaining when her husband signalled for her not to. They even rejected removal of Emla cream from the child's hands. When the NO returned, she instructed me to remove the Emla cream which I did, stopping them as they exit along the ward's corridor to do so.

In the end, the NO reviewed the case with me. She instructed me that in future, for new admissions, always give the medication first to avoid such claims of no interventions done. Fortunately, my colleagues had sent the child for AXR which was completed with report, in-time for their discharge. Thus the mother's claim of "no intervention done" does not hold water. Later, SSN Y advised me that if I was too busy to handle admissions in future, I should seek the NO's help. Lessons learnt.

Busy day

My team started with 11 patients this morning, including 2 that were just admitted with interventions to follow-up. There were 2 discharges. Then there was another admission by mid-morning. At around 12pm, 1 patient upgraded to a double-room and was moved to the other team, while I continued to manage his medication. Then, there was another admission which discharged at-own-risk subsequently.

The ward manager (NO) was in-charge. SSN Y and I were taking the teams near and far from the nursing station respectively. Initially SSN F from the adjoining ward helped as runner. She helped to empty a colostomy bag on my side. Then SSN Y got her help with her team's medications while SSN Y cover as in-charge, because the NO was busy in her office. After that, SSN F was re-deployed to the adjoining ward, which was opened to accommodate new admissions because my ward was full. On my side, the runner was HCA K was great with the HCA duties, but cannot help with EN level work and does not do admissions. On SSN Y's side, the runner was SEN S who is still not quite familiar with my ward.

Needless to say, I had a busy day. 2 morning medications leftover from the night shift (excluding the new admissions), 7 IV medications (including 2 discharges which needed IV antibiotics and removal of IV drip before discharge), 1 IV helplock, 4 patient education on medications, 1 new admission done by me, 2 IV cannulations. This is on top of following the doctors' rounds, pharmacy orders for top-ups and non-ward-stock items, answering call bells, assisting patients, 3 cases with nebulization, and medications for all. Would not have been so bad, if not marred at the end by the AOR discharge. In the end, I completed all my paperwork and billings, and left at 5pm! Thankfully, I managed to have a 15 minutes lunch break in-between.

Who's in pain?

As a paediatric nurse, I find myself learning about parenting do's-and-don'ts through observing real life cases along the way. One such interesting example is the mother of a recent GE case.

The mother was very agitated and fretful over her 3 years-old son. She rang the call-bell almost every 5 minutes for assistance and to highlight repeatedly that her child complained of pain. The mother varied her indicated location of the child's pain -- abdomen, IV drip site on the left hand, anus, generalized pain or some non-specific location. Here's my observation during one of those call bells.

I saw the child watching TV and the mother talking to the child.

“有沒有痛？有沒有痛？”, the mother kept pestering her child repeatedly, raising her voice and tone in agitation with each repetition of her question. ["Is there any pain? Is there any pain?"]

Her child was watching TV calmly. When the mother started raising her voice, he looked worried and confused at his mother. Finally, he lowered his eyes.

“是不是手？是不是手？” the mother continued in her agitated tone. ["Is it the hand? Is it the hand?"]

Then the child looked at his left hand with the IV drip in-situ. He seemed somewhat confused.

At this point, the mother then concluded, “Nurse 啊！Nurse 啊！我的兒子一直講他的手很痛，leh！” ["Nurse! Nurse! My son kept saying that his hand is very painful leh!"]

I walked over. Meanwhile, the mother walked away to the toilet. I asked to the boy calmly. “你那里痛？跟姐姐講。” ["Where do you feel pain? Please tell me."]

The boy looked at me calmly and then continued to watch his TV. No sign or complaint of pain whatsoever!

Reducing your child's fear

Had a good day today. SN L was in-charge, SEN L and I taking teams near and far from the nursing station respectively. SEN IV the runner for both teams. My team started with 5 patients, including a new admission done by the morning staff with the investigations, medications and IV cannulation outstanding. Admitted 1 more case later in the afternoon. Thus, I ended with a total of 6 cases. With some help from my runner SEN IV (who did the 2nd admission) and the in-charge SN L, I had time for dinner and toilet breaks, completed all work items and taped my hand-over report. I even wrote out some pharmacy "please supply" slips for the next morning's staff, so that she will know which items need re-supply. At the end of our shift, SN L, SEN IV and I left on-time and walked to our bus-stops together.

Fortunately for me, both new admissions today were not fearful of hospitalization. Neither the 3 years-old boy nor the 7 years-old girl cried during IV cannulations. Emla cream takes away the pain but not the fear. [Some of the children cry, mainly due to fear.] Both took their medications in their stride, even the yucky Klacid syrup antibiotics. My colleague SN L remarked that the parents of both children are rather calm about their hospitalization, and somehow that influenced their children. I agreed.

This reminds me of a GE case we had recently.

Code Blue Drill

We had a code blue drill yesterday.

I have re-certified my BCLS, Basic Cardiac Life Support, recently. I have yet to attend the LSCN, Life Support Course for Nurses, although we were taught the required skills in school. For my ward's code blue drill, I was designated as the second nurse-to-arrive, i.e. responsible for the chest compression.

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To prepare for the drill, my ward manager (NO), held code blue rehearsals on the day before and the morning before the code blue drill. At our first rehearsal, NO was role-playing the first nurse-to-arrive. When the code blue alarm sounded, I rushed into the room with the emergency trolley. Then the NO painted the scenario to me, "You see me trying to resuscitate the patient, what do you say?"

Thanks to my BCLS training, I automatically replied "I know CPR, can I help?"

"Of course you know CPR, you're a trained nurse!"

Ha ha. This became a joke that greeted us at work the next morning.

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JCI visitors paid a surprise visit to the ward just before our code blue drill. We, the staff nurses, prayed very hard that they would leave before our code blue drill started. Thankfully, our prayers were answered.

The code blue drill proceeded as rehearsed. I was focusing on the chest compression. There was a visiting admin staff who was trained on BCLS. She took over my compression after the "switch" count. Then all of us stood clear for the defibrillation. After the defibrillation, I continued with the chest compression. I continued to pump away until I felt a gentle slap on my buttocks.

Apparently the doctor had declared sinus bradycardia rhythm. I was so focused on the chest compression that I was still pumping away on a "patient that had recovered". My colleague SSN R, playing the role of the defibrillation nurse, gave me the discreet slap on the butt to signal for me to stop.