Dr Who?Here is a strange, sad case.
Relying purely on the press report, the following seems to have happened:
-The patient had a nasogastric tube inserted so that liquid feed could be placed directly into her stomach.
-A check x ray was performed to make sure the tube was placed correctly. NG tubes have a radio-opaque tip, and a check x ray is mandatory because they are inserted 'blind' and can easily end up in one of the lungs - feed in the lungs causes an iatrogenic aspiration pneumonia (ie: an infection caused by a health professional sticking food into your lungs). This is easily fatal, hence the paranoia amongst nursing staff about being absolutely, 100% certain where the tube is before you pour a pint or two of Gold Top down it.
-A male doctor the nurse identified as the Cover SHO told her the check x-ray showed the NG tube in the stomach and to commence feeding.
-The tube was actually in one of her lungs, so when Nursy opened the tap the patient immediately aspirated a perfect bacterial growth medium, promptly developed an aspiration pneumonia, and in due course assumed rigid room temperature (which, as we all know, is Not A Good Sign).
-On checking the notes, no doctor had made an entry about the check x ray.
-On checking the rota, the Cover SHO was a female.
-On checking the X ray logs, the doctor who looked at the x ray was not in the building. This, it turned out. was because the cover SHO had borrowed his login and password - which still did not explain who the mystery male 'cover SHO' was.
Two things about this interest Dr Rant.
Firstly, having worked as a medical SHO in Derriford hospital, I would like to point out that this is a very good example of Big is Not Beautiful and the perils of Discontinuity. Most hospitals are DGH (District General Hospital) sized. The government thinks this is Too Small, and want's economies of scale by closing DGHs and creating Super Hospitals. They base this on research from the US showing that Big is Better. They failed to mention that in the US, a Big Hospital is around the size of a current large UK DGH.
DGHs were designed to function using a single medical team (traditionally called a 'firm') of Consultant, registrar, SHO, and House Officer. This way, the nursing staff on the medical wards knew the 'firm' very well.
However, this has all changed. The 'firms' are gone; replaced by disjointed groups of doctors working shifts. The idea of medical patients being admitted to medical wards is gone: there are not enough beds for that. Now patients are scattered all over, and the nursing staff have to deal with conditions which are not part of their primary area of expertise and with doctors that they do not know as well.
Also, Derriford is a BIG hospital. When I worked there, it had several medical firms on duty at once covering different specialities. I'm not sure what a 'cover' SHO is, but the fact that they have so many SHOs that they have to give them special titles is not a good sign.
Secondly, as Mrs Rant has pointed out to me, nurses are obsessive about NG tubes (or, at least, they were and should still be). NH tubes move between x-ray and feeding time. They can dislodge or get pulled out and can end up in the patient's throat. Since the patient is not allowed to have food orally for a reason, and that reason is usually that they are at risk of aspirating anything they swallow into their lungs, this can be equally fatal. So, before each feed, the nurses syringe out fluid from the tube and use pH paper to check that it is acidic, helping to confirm the tube is still in the stomach.
It is a strange, sad, story from Derriford. I can't help but think that the causes of the tragedy are a microcosm of what is going wrong in the NHS in general.
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19 comments:
Good old days that I could still feel proud of. We were on call for the admission night, then the following night 2nd call to make sure most of the acute cases are settled. Third night we are off and mostly we crashed out in front of girl friend or something like that. Everybody knows everybody, Lead Consultant, Senior Registrar, Registrars, SHOs and H O s on the medical side and Nurses at every level too. Sisters who were experienced will see to it that us juniors perform all tasks properly. Everybody feels responsible at different levels with no fear that someone will blame someone else. We as doctors should be like parents as the Chinese saying goes, good parents of course.
How sad indeed.
The Cockroach Catcher
It's very strange that as the managers have suddenly got interested in team working they have ruthlessly destroyed the teams. As you say, only a few years ago it would not have been possible for this to have happened. Unfortunately arrogant managers, aided and abetted by the government, have taken the view that they know better than the professionals. In addition to team work they like to talk too about accountability. What better than the traditional firm structure to ensure accountability? But the traditional firm is sadly gone forever. Managers say one thing and do another. Which makes one wonder whether really they are just out to destroy professionals - aided and abetted by a government which certainly seems to have doctors, at least, in its sights. And of course we can't say anything so we have to vent our joint wrath here on Dr Rant - anonymously. How can this have happened?
I work at Derriford and this story is the 'talk of the mess'. The doctor scheduled to be on call that day had swapped their shift, something that happens on a regular basis. Therefore, not only is there no record of who actually worked the shift, there is no signature in the notes.
1 - The X-Ray was checked at 3am. Why do nurses feel they must wait until the dead of night until paging the on call doctor to comment on a non-urgent xray.
2 - Why cannot a nurse look at an xray and see the tip of a tube in a lung field. We've looked at the xray and it is clearly in the lung field and not below the diaphragm.
3 - Why has this been turned into a junior doctor witch hunt and not a clear systemic failure. Other trusts have better systems in place to avoid this kind of classic error.
4 - Why have people (media, trust) assumed that this was a specific doctor generated error and not a nursing error.
All sounds a bit convenient to me...
ps - Derriford hospital is big, and was the biggest non-teaching hospital in Europe before Tookes place was built.
Also, the fine bore feeding tubes make it difficult to aspirate stomach contents. The current guidlelines state that only pH testing and xrays can be used to confirm placement
I'd rather wait and see what the police investigation uncovers.
However, it has occurred to Dr Rant that one possible explanation is that the nurse 'imagined' Dr Mystery.....
The nurse could indeed be telling porkies.
Having worked on a liver ward were many patients required NGs, not to mention the frequent bowel obstructions, etc that require a nasogastric tube in A&E (admittedly not for feeding, but not very nice if its shoved down the right main bronchus ) - I can tell you that any nurse would be incredibly cavalier to start feeding without being 100% certain that the tube was in the right place.
Any nurse will tell you that cock ups, such as incorrect drug administration, often occurs at 6 o'clock in the morning, a period when the sensation of jet lag is usually at its peak.
The nurse should have satisfied him/herself that it was safe to begin feeding by examining the radiograph personally, and by checking the pH of the aspirate (since it was the first time the tube was going to be used).
I don't know if Derriford operates 'the hospital at night' system - but all the key players (medical & surgical reg, etc) usually take a hand over from the day staff, surely somebody, somewhere must know who this mystery SHO is ?
There is a good chance that the nurse has made up the check with the mystery SHO.
But there is also a good chance the doctor has screwed things up - either by not checking or by not knowing what he was looking at.
I persponally don't think this was a systems failure - it easy to blame everything on this - but clearly there was a system in place which is that the NG tube should not be used until it had been checked by an X Ray and by a fully trained doctor. No system can legislate against the people in that system accidentally or deliberately screwing up - the chances can only be lessened.
It must be relatively easy to find out who was on duty at that time - hopefully the truth will out.
If there are Xray logs it must be ascertainable whether or not the X-ray was checked - if so, and the doctor made a mistake, the gap in his knowledge can be addressed. If no-one bothered to check the X-ray because NGTs are almost always in the right place then that is unforgiveable and, if it is the doctor's fault, he should be found out and severely disciplined, if not struck off.
All the doctors on duty that night should have volunteered themselves by now to ascertain what went wrong.
Mistakes can be made in all areas of medicine but covering up at whatever level is a serious criminal offence called perjury. If a doctor did check and made an error he should own up now. If someone knew of him please urge him to. It will otherwise be worse. No one is immune. This one is not going away by ignoring it.
Unless of course he is in Bosnia.
The Cockroach Catcher
teaching hospital, 2 yr ago. i was fast bleeped to a cardiothoracic pt. crashing. i pick up her obs chart and surprise surprise, not a dicky bird.
by the time the consultant has arrived she had managed to find herself perfect obs, even after arresting
"we have been bleeping you all night" comes the chorus from fat nurse 1 and fatter nurse 2. consultant, who has been taking it the arse and mouth from both nurses for the last 10 yrs gives me a ration of shit.
until i bring him switches bleep log the next morning
gets put down to phantom bleep. and phantom obs fairy.
cant upset the poor hardworking nurses from those brutal bullying doctor bastards
my experience has taught me this - a nurse will cover her back by all manner of invention, deceit regardless of the obviousness of the lie
in the same way "doctor informed" is always about self preservation and fuck all to do with looking after the patient. you know the same patient swimming in a sea of their own shit for the last 12 hrs
It's always seemed strange to me why NG tube Xrays need a doctor (who, out of hours is unlikely to have even met the patient in question) to see if the tip is above the diaphragm.
In my opinion, it makes much more sense for the person who actually places the NG (doctor or nurse) to take responsibility the position of the tube before feeding commences.
This is what happens in the USA and, I think you'd have fewer mistakes if people had a greater sense of "ownership of the problem." It seems to me that in this case, the buck was passed from one person to another to another until some poor chap dies.
We can do better.
RE: "It must be relatively easy to find out who was on call"
My understanding of the case (from the media and from local mess gossip - I work nearby) is that they do know who was on call. It was a female doc.
The nurse insists it was a male doc who saw the XR.
To me this supports Dr Mystery being invented or "misremembered". To suggest a completely invented but to me plausible scenario...
Nurse X decided to start feeding as no one is answering the bllep she's put out. Of course she's been bleeping the wrong number but hey that's ok. To make sure she doesn't take the flack she writes in the nursing notes "Dr on call has reviewed XR and HE says is ok to feed." Now she's written he in the notes, shit is hitting the fan, what does she do? Has she got the balls to blame the completely innocent female doc who was on call? When it comes down to it no so she sticks to her guns about the male doc. And the cirus continues.
"a nurse will cover her back by all manner of invention, deceit regardless of the obviousness of the lie".
"fat nurse 1 and fatter nurse 2".
"you know the same patient swimming in a sea of their own shit for the last 12 hrs".
Blimey, anonymous - I wonder if your nursing colleagues have such a high opinion of you ?
I admire your penetrating insight (blame fat nurses) and the way you steadfastly refuse to generalise - you've captured, perfectly, the mindset and clinical standards expected by our profession.
Thanks for providing such balanced and informed observations, as I say, it must be a real treat having you on shift ?
By the way, you did not elaborate on the role you provide, perhaps you would care to share this with us, come on, you don't have to be so bashful.
Sadly, A&ECN, the description of nurses lying to cover their mistakes is increasingly one all doctors recognise.
I'm sure there could be many reasons that such behaviour appears to be rising dramatically. I doubt it is linked to being overweight, but it is hard to deny that the 'fat lazy key jankling psyco nurse' is a stereotype for a reason....
The bit anonymous missed was that usually two nurses countersign false entries to make the lie unassailable.
Let's wait and see what the police say.
Thank you Dr Rant.
I can accept that individual nurses are a disgrace to the uniform - but our anonymous contributor lapses into crass generalisations, bolstered by tedious references to nurse fatties and shit.
This tells us a great deal about his/her (vindictive) attitude - the urge to apportion blame has rapidly overtaken any fair hearing that might have been afforded to the protagonists at Derriford - some very clever individuals, it seems, simply do not need to bother themselves with the facts in order to make judgement.
But if we can we generalise about nurses, surely it's OK to throw in a few negative medical stereotypes as well ?
For example, aren't medical locums inherently slack money-grabbers?
And then there is the issue of inadequate medical leadership, what does it say about a team that was apparently unable to identify, or recall its own members, on any given night shift ?
I despair when docs/nurses lapse into a slag fest after a terrible cock up.
Openness is always the best policy, even after a dire error, because extenuating circumstances nearly always result in clinicians having reasonable grounds to defend their actions - while subterfuge is a far riskier strategy (especially if your lies are ever found out).
I must admit in my little corner there is absolutely no evidence to suggest that nurses are increasingly devious and unwilling to accept responsibility for their actions (as seems to have been suggested here).
Maybe some of the other docs/nurses interested in this thread will have a view on it - and if nurses have finally morphed into idle, lying, fat shit loving scumbags does anyboby know why ?
For example, aren't medical locums inherently slack money-grabbers?
No, but I've met the people the stereotype is based on.
I despair when docs/nurses lapse into a slag fest after a terrible cock up.
So do I. But I despair more about the causes of the degeneration: undervalued staff, underfunded, undersupported, overworked, underpaid poor sods who either burn out, drop out, or go mad.
Make no mistake where the real blame lies. And it is not on the front lines.
dear a+e charge nurse
i am a surgical trainee and was a cardiothoracic sho when obs-gate occured
an "investigation" was carried out. the 2 nurses were indeed found to dishonest. the consultant under pressure from the ward manager to acquiesce did so. both resumed normal duties without censure
if i was indeed as vindictive as you presume, i would have contacted the NMC. instead i chose or allowed myself to believe that a verbal warning was issued
a culture of closing ranks and apportioning blame elsewhere has becoming rife amongst a not insignificant no. of nursing staff
The trouble starts when you can no longer trust the people you work with, doctors or nurses at least, I know you can no longer trust the managers. Now if you cannot trust your medical chief, can he trust you?
C’mmon. We are suppose to be saving people, not filling forms, meeting quota or acting according to half baked protocols. I was told I was an independent professional.
The Cockroach Catcher
Forgive me, anonymous. but 'closing ranks', and 'apportioning blame' are phrases that are more typically ascribed by (some) members of the public to doctors (after untoward incidents).
Unfairly perhaps, but the perception certainly exists.
http://news.bbc.co.uk/1/hi/uk/682000.stm
It is said (in medical folklore) that a doctor does not truly become a doctor until he/she has killed somebody ?
Of course this does not reflect latent homicidal tendencies, rather the near impossibility of getting complex clinical decisions right every single time (especially at 3 o'clock in the morning when you are exhausted/stressed, etc).
Personally, I don't think we can blame doctors for this reputation (for self preservation), the vast majority are honest but their mistakes are complicated by a minority of bad apples who are less scrupulous about the consequences of their misdeeds ?
By the way, my accusation of vindictiveness had nothing to do with the nurses highlighted in your vignette.
If ANY nurse fabricates obs, then they are a liability not only to the profession, but to the organisation, and most importantly to patients - premeditated lies/deceit should invite disciplinary measures, that go beyond a token verbal warning.
After all, how can anybody trust these charlatans again ?
And if trust is lost then we really are in the shit.
But to suggest that more and more nurses are opting for an integrity bi-pass is an unpleasant accusation, I wonder if the evidence for such claims goes beyond personal anecdote ?
"Forgive me, anonymous. but 'closing ranks', and 'apportioning blame' are phrases that are more typically ascribed by (some) members of the public to doctors (after untoward incidents)."
Ah, but nurses seem to want to be doctors in so many ways now ;)
It would seem logical that as the 'system' becomes more institutionally corrupt (corrupt managers 'hitting' corrupt targets) and the pressure on nurses rises (less nurses, more patients) that this behaviour will become more prevalent.
It is a symptom of a greater malaise.
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