James couldn’t lie flat on the bed because his body wouldn’t allow him. Instead, he sat on the edge of the bed, his shoulders hunched forward, trembling hands gripping his knees as he struggled to find the energy to keep himself upright.
‘Nothing works,’ he managed to say before pausing to get his breath. ‘Can’t you give me something stronger?’
I nodded my head.
As I listened to his chest, checked his blood pressure, pulse and oxygen levels, my mind had already come to its own conclusions. This 17-year-old boy had neglected himself, and seemed determined to continue to do so.
It was frustrating, because James was asthmatic and a heavy smoker, and he was literally guaranteeing himself a life of lung disease if he continued.
But I could also sympathise with him, because he was only 17, unkempt, in hospital alone, with no family or friends around him. I even felt a little empathy, as I remembered being a teenager and feeling like the world was against me.
I asked James what he normally takes for his asthma, and was presented with a Ventolin inhaler; the most common one around, used to treat an actual asthma attack.
‘Is this all you have?’ I asked. He just shrugged his shoulders.
‘It’s what the doctor gave me, and it doesn’t work.’ He paused for breath, but he sounded angry. ‘The doctor’s useless.’
I gave the inhaler a shake, and found it to be empty.
‘You do know there’s nothing in here?’
James scowled at my comment. ‘I’m not stupid! But it doesn’t work anyway, even when it’s full.’
He hadn’t had any Ventolin in over a week.
Instead of getting into an argument with him, I got the doctor to quickly prescribe a nebuliser. This is a mask that sits on the face, and provides oxygen, mixed with medication, that the patient can breathe directly into their lungs.
Once this was up and running, I took the opportunity to find out some more about my patient.
‘Have you been back to your family doctor, and told him it doesn’t work?’
James shook his head.
‘Why not?’
‘Why would I? His medicine doesn’t work.’
I was getting nowhere with this line of discussion, so I changed the topic.
‘Have you ever tried a preventer?’
‘Don’t know. That’s my preventer there, isn’t it?’ he said, referring to his Ventolin inhaler.
It was surprising to see that he knew nothing about his asthma, and while it was also frustrating that he didn’t seem to care, it was sad that we weren’t going to be able to make any real changes here. We’d get his breathing settled, and then probably send him home, from there it would be up to him to follow up with his family doctor.
‘Well, there are actually lots of treatments your doctor could try. And your Ventolin inhaler isn’t a preventative – all it can do is relieve the symptoms of an attack. You need to talk about what else is out there with your doctor.’
I explained how dangerous it was to smoke when you had asthma. I even went as far as to say that if he kept on smoking, he was almost guaranteed to end up with lung disease. But I could sense that these words had no effect, after all, they’re just words.
I left James alone to give him a chance to mull over what I’d told him. I informed the doctor of how things were.
‘When can I go home?’ After three hours in the emergency room receiving treatment, James was much improved. His breathing had settled completely, the wheezing in his chest had nearly gone, and he could lie back on the bed and relax. He even dozed off for an hour.
‘Where is home, James? Can we call your parents to pick you up?’ James explained that he didn’t live with his parents, but with a group of students. He didn’t want his parents to be involved.
I left him in the doctor’s capable hands.
At the end of treatment, the doctor gave the usual advice about the need to stop smoking, and the need to be more proactive in his own care. He also reiterated what I had said earlier, about the deadly combination of smoking and asthma, adding that 80 per cent of people with lung disease were smokers. He was given a new inhaler, and the contact details for an asthma support/education programme.
I was working the following Saturday evening when James presented to the emergency room again. His asthma was playing up, and he was also complaining about how useless the inhaler we had given him was. His problems were exacerbated by the fact he’d developed pneumonia. Generally a young man of James’s age would not need to be admitted to hospital for such a diagnosis – he’d be able to be at home while taking antibiotics – but James was too unwell.
‘I told you it doesn’t work, and you sent me away.’ Even though James’s anger seemed directed at me, it was really directed at everyone.
‘Listen, mate, let’s play the blame game later. Right now, we just want to get you better. And you’ll have plenty of time to get yourself sorted out, because you’re going to be admitted.’
James lifted his head off his chest. ‘I’m not staying in this shithole, no way. Just give me some proper medicine, something stronger, like you did last time.’
I tried the honest approach. ‘People die from asthma – young people like you. If you have a death wish, you’re free to go, right now. We won’t stop you.’ Amid much moaning and fuss, James let himself be admitted to a medical ward.
When I transferred James to the medical ward, I was pleasantly surprised to see that it was Gwen who was going to take over James’s care. She had been a nurse in the NHS for 25 years, and in the process had managed to raise three teenage sons and one daughter. If anyone could get through to James, it was her. Gwen wasn’t one to just do her job, and give out medicines and advice that would most likely be ignored. She did whatever it took to make a change.
James would be sharing a room with three elderly men; two heart attacks and a stroke (no offence intended, but it’s not unusual to identify patients by their illnesses). It was James’s first time sharing a room, as well as his first time staying in a hospital overnight.
The effect of being in a hospital ward, seeing, hearing, smelling and feeling what it’s like, is sometimes enough to bring about a change for the better. It’s often a wake-up call. Unfortunately, it seemed to have no impact on James.
After two days of intravenous antibiotics, James hadn’t improved. Gwen put it down to the fact that he spent most of his time outside the front door of the hospital, in the cold, smoking. He’d have a cigarette or three, and then wander back to the ward for his next antibiotics or nebuliser. Something had to be done.
Gwen went to James’s room and began packing up his things. ‘What’s going on? Am I being moved?’
Gwen nodded her head, and kept on packing.
‘Where am I going?’
‘Home, of course.’
James sat stunned. He began to protest, but Gwen cut him off again.
‘What’re you moaning for, boy? You kicked up a fuss about coming here. I would’ve thought you couldn’t wait to get out of this place. Or don’t you want to get out?’
James was caught off guard by Gwen’s attack. ‘Ah . . . yeah . . . yeah, I want to get out.’
‘Well, at the rate you’re going, the only way out of here is in a box. What don’t you understand? You’re killing yourself. I hope it’s quick, for your sake.’
James rallied. ‘You can’t talk to me like that.’
‘Why, does it upset you? Does the truth hurt? Why do you think I’m talking to you like this? Why?’
James was speechless.
‘Because we might care, but we can only do so much. You have to start helping yourself. I want to help, but I’ve got other patients who need my help, and are willing to listen. Are you going to start listening to me from now on?’
James nodded his head. ‘I’m sorry,’ he finally stammered.
James didn’t change overnight.
The real progress began when Gwen took him to visit some of the patients with CORD. This stands for Chronic Obstructive Respiratory Disease.
CORD is a chronic disease of the lungs, meaning, once you’ve got it, it’s there for good. You might have your good days, or your bad days, but as time goes on, it inevitably gets worse.
When Gwen said she hoped his death was quick, she was referring to this disease. Think about running a 100 metre sprint. Now remember how puffed out you were at the end of it. A lot of the people with CORD don’t die quickly and they linger for years, for decades even, and constantly feel like they’ve run a race.
James spent 20 minutes with two patients, Keith, who was only 47 years old, and Bill, who was 70 years old. Bill had been short of breath for the last 30 years, and it looked like Keith might follow in his footsteps; that’s if he didn’t die quickly via stroke or heart attack.
Within three days of his visit, James was discharged. He’d stopped going outside for cigarettes. He let Gwen set up meetings with the respiratory nurse. He began showing an interest in his treatment and what he could do to prevent an asthma attack. He signed up for the hospital-funded stop smoking programme. He did everything he could to get better, and he got the results he wanted.
Several months later, Gwen received a letter from James. In it he thanked Gwen for helping him turn his life around. He explained that he had managed to completely give up smoking, and also stated that he had only had one mild asthma attack since discharge. The letter was also accompanied by a box of chocolates.
The chocolates were a nice touch, although the real reward for Gwen was in knowing she had saved a young man’s life. It would have been easy for the nursing staff to give up on James. They could have just gone through the motions, such as giving him antibiotics and nebulisers, and hoped for the best. Nurses have enough work on their hands with patients that want and appreciate the care they receive, and it’s sometimes hard to do that little bit extra for someone who resists.
But nurses like Gwen aren’t rare – many will go out of their way to give the best care, even when the patient doesn’t want it. They’ll do whatever it takes, often that little bit extra (which money can’t buy).
It’s not always a single error that kills. Sometimes it’s a collection of problems, or conditions, that combine with devastating results. The story of Mr Benson was one of these combinations.
Day 1
Mr Benson shouldn’t have been here but there was nowhere else for him to go. He needed to be in a less hurried place, somewhere more relaxed, but most importantly, a place that had the time to give him the care he needed.
The nurse escorting Mr Benson from the emergency room explained that he was suffering from pneumonia. He was 79 years old and normally fit and well with no medical history.
The nurse explained that he was normally independent, and for intravenous antibiotics only, and should be straightforward to look after.
At those words I looked down at Mr Benson, who lay slumped against his pillows, his chin resting on his chest. Like all less able patients, he looked to be in the most uncomfortable position possible. He might normally be independent, but the foul infection nestled at the base of his left lung had sapped his strength.
‘I can’t thank you enough,’ Mr Benson said to me later, as I was administering his antibiotics, ‘you’re all so good to me.’
Mr Benson probably didn’t realise he shouldn’t be here. A glance at the three other men in the room told a story of its own. The sight of intravenous drips, drains, catheters, wound dressings and pumps was not the sort of equipment a medical patient like Mr Benson often needed. This was a surgical ward and I hoped none of these patients would catch Mr Benson’s chest infection, or even worse, get a wound infection, from him coughing and spluttering all over the place.
Day 2
I had three patients for theatre today and nine other patients all in varying stages of post-surgery recovery; it was all a bit much.
‘I haven’t had a decent wash in over a week,’ Mrs Jones complained to me. ‘When are you going to take me to the shower?’
Mrs Jones was on bed rest for leg ulcers and was desperate to get out of bed.
‘Maybe later this morning,’ I replied, although I knew I would disappoint her. ‘I’ve got to go to theatre now, it’s pretty busy.’
I left her room before she could voice another complaint.
‘You’re supposed to change my dressing four times a day,’ Mr Smith declared. ‘It’s eleven o’clock and nothing’s been done.’
‘Sorry, Mr Smith, I’ll try to get to you soon. My patient from theatre is not very well.’
The look on his face softened.
The patient who had just come back from theatre was Mrs Wright. She had lost quite a bit of blood, but was in the process of being transfused, so should be okay. The doctor said that when they opened up her abdomen, the tumour was bigger than expected, but they think they got everything. I was supposed to check on her every half an hour, but sometimes it was nearly an hour before I could make it back.
‘My mother has been sitting on the commode for 20 minutes. This place is a disgrace,’ said the daughter of Mrs Blake. ‘What sort of establishment is this? I’m going to write a complaint.’
‘Please do,’ I replied as I helped Mrs Blake off the commode and left.
Sometimes as a nurse you may not be allocated a patient one day that you’d had the day before. Even so, I try to keep up to date with how they’re doing. I usually poke my head in their room, even if just to say hello.
This was the case for Mr Benson, and I was saddened by what I saw. It was nearly lunchtime and Mr Benson, my pneumonia patient from yesterday, was still in bed. He’d slid down the bed and was hunched in a ball, his shoulders up by his ears and his head on his chest. Why hadn’t anyone thought to get him out? I suppose because no one was around to do so.
Sitting at the bedside holding his hand was another hunched figure. Mrs Benson. It should have been a touching scene, but instead it was depressing.
‘Good morning, Mr Benson.’ He lifted his head off his chest and gave me a smile.
‘Oh, good—’ He was interrupted by a bout of coughing that racked his whole body. When it finally passed he spat some foul greenish black sputum into a jar. I had a peep at his drug chart. Sure enough his ten o’clock antibiotics hadn’t been given. I didn’t have time to give them to him because I was overdue to check on another patient, but there was not another nurse in sight.
Back on my own side of the ward, I was running ten minutes late having decided to administer Mr Benson’s antibiotics after all. My next patient, Mrs Wright, needed a fresh unit of blood. I noticed her narcotic infusion was nearly empty, so that would need changing, plus she was due some antibiotics, although to be precise she was an hour overdue for them, but an hour wasn’t too bad, at least not in this place. Forty minutes later and Mrs Wright was back on track and everything was up to date.
‘Any chance you can do my dressing now?’ Mr Smith asked.
He was no longer angry, he sounded almost resigned to his fate.
Day 3
I had the afternoon shift, with a total of 14 patients, none of whom was Mr Benson.
‘I’m just going to the other side for a moment,’ I explained to Trixie, my nurse assistant for the afternoon. ‘Can you please take Mrs Blake off the commode? If her daughter yells at you just tell her to write another complaint.’
Trixie stalked off in the direction of Mrs Blake’s room. I had the impression she didn’t understand my type of humour. She was only 19 and in her second year of nursing school, and the poor thing seemed overwhelmed. I couldn’t help but wonder if this experience would put her off nursing for good.
Trixie shouldn’t have to deal with angry patients or family, so I still occasionally had pangs of guilt whenever I sent her off to do an unpleasant job, or deal with a potentially difficult situation. Unfortunately, when you’ve got such a huge workload, there’s no choice.
‘Good morning, Mr Benson,’ I said, as I entered his bay, expecting to see him still in bed. But Mr Benson was out of bed, and well before lunchtime at that. But it still wasn’t looking like a good morning for him. He had slipped so far down his chair that it was only a matter of time before he would end up on the floor. I tried to lift him up but he was too heavy. He was not a particularly big man, but he had no strength to help me.
‘I’m stuck,’ Mr Benson managed to say, before bursting into a round of coughing. The bout of coughing made him slip further down the chair.
‘Hang in there, I’ll grab some help.’
There was no one around. Whenever I needed someone it was almost as if everyone went into hiding.
‘Excuse me, can you help me a moment?’ I asked the lady cleaning the floors. She looked startled; perhaps because I was the first staff member to talk to a cleaner. She remained silent but followed me into the bay. ‘I need a hand sitting him up,’ I said, indicating Mr Benson.
‘I’m not allowed to do that,’ she said, ‘I’m not trained.’
I was sure I didn’t hear right.
‘I just need a quick lift, only take a moment. I won’t tell.’
Once she made up her mind, she did what she knew to be right and didn’t waste any time helping me sit Mr Benson up.
‘I’m sorry I didn’t help right away. The boss says we shouldn’t get involved with the patients. Legal reasons and stuff.’
When the cleaner left Mr Benson clasped my hand.
‘You’re good to me,’ was all he said before succumbing to a bout of coughing.
Day 4
It was the start of the shift, and I made a plea to the nurses to keep an eye on Mr Benson. Everyone agreed to make an extra effort. Claire even put in a request for extra physio.
But this patient needed more than physiotherapy. He needed to be mobilised regularly and not just when the physio came. He needed to be got up out of bed. He needed to not be left slumped in his chair, or forgotten in his bed for hours at a time. He needed his antibiotics on time. He needed to be encouraged to eat and drink. He needed what time wouldn’t allow us to give, although we were quite capable of giving, and that was basic nursing care.
I suggested that he be transferred to a medical ward.
Things happen at a slower speed in a medical ward. At the very minimum there’s not the hurried rush to get someone to theatre, pick patients up from it, less intravenous fluids to monitor, none of the intensive immediate post-op care. As for skills, it’s not unusual for nurses to be specialised in surgery only, or medicine only. I’ve known many surgical nurses not know what to do when their surgical patients develop medical problems, and vice versa. Fortunately, at that time, I had experience in both.
I found Mrs Benson at her husband’s bedside again. In the same seat, and the same position with her head bowed, holding her husband’s hand in silence. She had not let anyone know she was here. She couldn’t make it every day because she was unable to drive and was reluctant to use the bus because of a fall getting off one a year ago. She couldn’t afford a taxi. She had to rely on the warden from the supervised accommodation where she and her husband lived. The warden tried to make a trip to hospital every day, but this was not always possible.
‘I’ve never seen him so frail.’
It was the first time Mrs Benson had actually spoken to me.
I nodded my head and sat down on the side of the bed.
‘We’re doing all we can. Can I get you anything?’ I asked her.
‘Tea would be nice.’
I hurried away and got both Mr and Mrs Benson a cup of tea. It was the first time I had managed to sit down with Mr Benson and not be interrupted. There was work I should be doing, but it would have to wait.
Day 5
Mr Benson wasn’t my patient today and I only saw him once. He was being wheeled past me in a wheelchair, on his way back from X-ray. He didn’t notice me, but I took the chance to look at the results and was disappointed to see there was still a large white area at the base of his lung. I looked at his previous X-ray, taken on admission, and if anything the white area seemed more consolidated. The antibiotics weren’t doing their job.
Day 6
Mr Benson had been moved to a single room in the middle of the ward, right in front of the nurses’ station. During the night he had developed an extremely high temperature, 39.8° centigrade. Even before I entered his room, I could hear the rattling noises coming from his chest. He no longer smiled, he was too exhausted. When open, his eyes were rheumy, but, most of the time, his eyes were closed. He was drifting in and out of consciousness. His antibiotics had been changed to the strongest that the hospital had to offer, but I didn’t think it was going to be enough.
Mrs Benson was sitting at her husband’s bedside.
‘He’s very ill,’ I said, as sensitively as I could.
‘I know,’ she replied. She wasn’t crying, but the expression on her face said it all.
‘He had a rough night, but we’ve started him on new antibiotics,’ I said.
It was always easier to talk about the treatment than the prognosis. I didn’t want to bring up the subject of death, but the right thing to do was to find out if Mrs Benson was aware exactly how sick her husband was and that this was a possibility.
‘Hopefully the new antibiotics will help.’
I watched Mrs Benson closely to gauge any reaction. She showed no sign of having heard me.
‘We should know soon if they will help,’ I added.
She turned her head towards me.
‘What do you really think? Please.’
I felt a lump in my throat, but as much as the truth would hurt, I had to tell her.
‘It’s not looking good,’ I began. ‘He could get better, but the infection seems to have spread. His whole body is battling it.’
She nodded.
‘Is he suffering?’ she asked.
I looked over at Mr Benson and his eyes were closed. His temperature was down and even though he looked horrendous, I judged that at the moment he was not suffering.
‘He’s not in pain,’ I said.
‘Thank you.’
Day 7
I was allocated Mr Benson today. I asked Claire if we had a resuscitation order for him, but was told not yet because they wanted to wait until another family member was here to discuss the matter.
He was alive. The rattling in his chest was still there. It was a lot quieter, but that wasn’t because the infection was improving, but because his breathing was so shallow and irregular. He would breathe two or three slow breaths, and then pause. Mr Benson had no control over this, as he was no longer conscious.
The nurse assistant and I went to turn him on to his other side, and as I placed my hands on his arm and hip he felt cold, lifeless.
We began to roll him from his side and when he was on his back the assistant gasped, ‘He’s stopped breathing.’
I felt for a pulse, and to my surprise found one.
I ordered the assistant to press the arrest alarm. I didn’t want to. Mr Benson should have been left to die in peace, but the choice wasn’t mine to make. I placed a bag over his head and began to breathe for him. The arrest team arrived in moments.
The doctor couldn’t find a pulse and I was told to commence compressions.
I began to press on Mr Benson’s chest and had to clench my stomach as I felt a familiar crack. I don’t think I’ve ever managed to do compressions without breaking a few ribs.
8 p.m.
There were two doctors plus two specialist arrest nurses. They relieved me from the compressions; my arms were tiring. I stood back and watched. It was a shame the doctors couldn’t see there was nothing more to do, and ironic that Mr Benson was receiving all this intense attention, from so many people now, when all he needed was a little attention to begin with.
It felt like forever, but finally everything was over, the doctors were defeated. Mr Benson was pronounced dead.
Maybe Mr Benson would have died regardless of the level of care he received. Maybe it was his time. The painful thing is that we never gave him a chance. What would have helped during that week is another registered nurse. Two registered nurses plus a nurse assistant may have been enough to give Mr Benson a chance at survival. Still, I felt guilty.
I felt guilty about Mr Benson’s death because I knew that his care could have been better. It was frustrating because I felt that I just couldn’t give the care I knew I was capable of giving.