Tuesday, 14 July 2009

Relatives in Resus?

A reader writes :- i did an agency shift in A/E they put me in resus ... the charge nurse said that relatives are allowed to watch the resus. now i may be out of date. in my day they waited out side. what do you think ?

Well...serious question and a difficult answer that is always going to offend someone somewhere...no change there then !

I know that I adopt a rude,sarcastic and often elitist tone in my postings...and I am by nature irreverent,possessed of an infantile sense of humour and I am also just a little bitter and twisted...but...in truth I am actually a passionate trauma-nerd nurse who strives to deliver expert care to the continually ungrateful lumpen proletariat and their ugly children...

And so...and so...I believe that there is a place for the family in the resus room...although it needs to be carefully managed and constantly monitored by a senior nurse doing family-liaison duty...

I first went to work in the Accident Unit at the Joburg General in Hillbrow on a Friday night/Saturday morning in April 1977...four months into my training...

I remember walking in to absolute bedlam...John vd Marde,the doctor...(and wearing a white safari suit with shorts!!)...was attempting to suture a drunk who was being held down by three policemen...also wearing shorts...blood and chaos everywhere...with Tish Minne the Night Sister,in full 'bitch-mode' overseeing everything...
I fell instantly and irrevocably in love...with Trauma...not Tish!

And as a student nurse and then Registered Nurse I just lapped it up and internalised the ethos...the "We are better than anyone anywhere,doing any sort of job" ethos that is still so prevalent in emergency care...and the truth is,that when you are in your twenties and being expected to perform unspeakable acts on complete strangers,there is a sense that you need to feel a certain shared sense of achievement and pride...

But too often young graduates think that they have entered some holy Templar Order of Trauma...and that only the elected priests and suitable shriven and blessed acolytes may worship at the hallowed Cathedral of Catheters praising St Foley,St Swan-Ganz and St Tenckhoff...

That thinking ,will in the end,just kill you...emotionally,professionally,psychologically...if not actually...I will never forget my kind friend and excellent doctor Graham for whom it all became too much...

But of course...with luck...and the love of a good women...you start to question your practice...all aspects...the professional,the technical,the sociological...the context in which you work...and of course,at some point you have children of your own.

And so,working in Children's casualty at the Johannesburg Hospital...I gradually realised that we were not doing everything that we could for the grieving families who came our way.

Most importantly...I just developed the belief that ...if you were present when your child was born...then you should be present when your child is dying!!

A novel concept...and one for which ...in 1988...I took a lot of flak.

Fortunately,both Dr Pincus Catzel,the HoD;and Alan Rothberg the Professor of Paediatrics,both supported my idea...as did most of my nursing colleagues...and since the Registrars and SHO's were all on rotation through the Unit,they just did as they were told!

And then Dr Walter Kloeck gave me a platform to present my work at Wits Medical School on the post-graduate Diploma in Primary Emergency Care .

Of course there were many many reasons why I took this viewpoint...some specific to South Africa...some due to my personal journey...but the situation outlined below...was the overwhelming reason why I thought things could be better managed in our Unit.

This is an excerpt from my book...Darktime:The sudden death of children.

There were all sorts of reasons why this protocol was developed, most of them simply practical and structural. In the South Africa of the day, many people did not even share a common language and so it was difficult to communicate with them.

A Resus one bright, hot, summer morning in 1989 put a completely different spin on the need for our ‘open Resus-room door’ policy.

A drowned toddler was flown in by the Johannesburg Hospital’s Flight-for-Life helicopter.

I did a “hot offload” and ran directly to the Resus Room.

It so happened that it was a “Grand Rounds” day and so everyone who was anyone in paediatrics was in casualty. We started the resuscitation with the Professor of Paediatrics and the Casualty Consultant calling the shots.

At some point, the child’s mother and grandmother were brought into the Resus area and stood next to the wall watching us for about two hours.

Eventually it was decided to stop the Resus.

As the senior Nurse (and at a time when I was taking a break from the CPR) I spoke to the mother and asked them to accompany me to the relatives’ room whilst we just “tidied up” the room-in effect, whilst the ET tube was removed.

The three of us sat in the room and I started to explain everything that we had done.
The grandmother interrupted me saying that she was a Nurse and in fact “knew” that her grandson was dead when she had found him floating in the swimming pool.

What she said next fundamentally altered my practice as a Nurse.

She said that when the ambulance had arrived, that she thought that because the Paramedics were white, and her grandson was black and that this was after all apartheid South Africa, that they would not bother to attempt to rescue her grandson.

But they did.
They jumped into the swimming pool, pulled him out and started CPR.

Within a few minutes, the Response Car arrived.

Again, she said, because the Doctor and Nurse were white and her grandson was black, she thought that they would not resuscitate her grandchild.

But they did.
Within a few minutes the helicopter arrived. Not only were the Pilot, flight doctor and flight nurse all white but the helicopter itself was painted white!
Again she thought, they wouldn’t do anything because they are white and he is black.
But they did.
She arrived at the Johannesburg Hospital (having been driven by the Response Car crew) to see me do the hot-offload.
Again she thought, this is a white hospital and he is black and they won't do anything for him.

But we did.
As she was able to witness.

She said to me that she thought that we were going to go into the Resus area, close the door, wait a few minutes and then come out. Instead, she and the mother were brought into the Resus room and watched us trying to save her grandson.

For all the many reasons why this protocol was developed, it was never because we thought that black South Africans would think that white South Africans would not resuscitate their children.

You just never ever know what is happening in the families’ hearts and minds!

If you would like a copy of the paper that more fully explains the rationale behind the Johannesburg protocol,and which I gave at the Second International Conference on Children and Death in 1992, please send an email to darktimebook@yahoo.co.uk

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