Category Archives: Ideas

Palliverse’s Greatest Hits from Oct 2014 – #getjakbak revisited – Part 5

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Photo by Ricardo Gomez Angel on Unsplash

Touchdown. Phew. Thank goodness for that.

As the rest of the passengers vacated the plane and went through in my head how to reassemble the collapsible stretcher that I would use to carry him off the plane. My patient had limited mobility and would not be able to help much in the transfer. I would have to reassemble the stretcher around him. As the final passengers left the plane I prepared the stretcher. Putting the left side down on the bed underneath his back, underneath the bedsheets as I had been instructed. I then asked him to roll towards me on the other side, which he was able to do, whilst I placed the other part of the stretcher underneath his other side. Hmm, there’s supposed to be a clicking sound as the pieces snap together. Why isn’t there a clicking sound?

I felt for the location of two pieces underneath the patient, Oh they are slightly misaligned. A slight shove upwards of the right side piece and CLICK it went into place. Okay just need to put together the head and feet components, then strap the patient in. By this time four burly porters had made their way to our seats, ready to help carry our patient off the plane. I gathered my medication bag and other equipment and we walked down the aisle to the back of the plane.

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Palliverse’s Greatest Hits from Oct 2014 – #getjakbak revisited – Part 4

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Photo by Hanson Lu on Unsplash

His lips were blue and his breathing had become erratic as we had reached cruising altitude. I measured his pulse oximetry again, it had been 95% on the ground, now it was 89%, and his heart rate was 120. I attached the tubing to the oxygen cylinder and then placed the prongs into his nostrils. His readings started improving and his lips returned to their usual colour. He had nausea and I gave him an anti-nausea injection. I asked him if there was anything else he needed, he shook his head. He was exhausted and in a few minutes he fell asleep.

Although I had already been a doctor for 13 years by this stage, working on this medevac flight was different to what I was used to. As doctors we usually see our patients briefly. The longest time we spend is usually during the admission process, we might spend 30 to 80 minutes seeing the patient for the first consult. In the hospital/hospice setting further follow-up visits are usually short, maybe 5 to 10 minutes. The rest of the time between visits the care is provided by the rest of the team, especially our nursing colleagues. So it is possible that during a week long admission, that a patient might only be seen face to face by their doctors for two hours or much less in total.

During the flight it felt like I worked half a nursing shift. As an untrained beginner nurse I kept an anxious eye on my patient. My head was constantly tilted towards him, watching his chest moving up and down. Making sure that he was still breathing steadily. He awoke halfway through the flight in pain, and more pain relief was administered. He stirred a few more times, as if he was having a bad dream. All throughout the four hour flight I checked on him at least once a minute. This was an exhausting vigil to maintain driven by my own anxiety more than anything else, one on one nursing is hard work. We were getting closer and closer to his home. I silently willed him to hold on a bit longer, that he’d be able to see his family soon.

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Palliverse’s Greatest Hits from Oct 2014 – #getjakbak revisited – Part 3

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Photo by Elena Mozhvilo on Unsplash

I didn’t sleep well that night because of a mixture of emotions; excitement, fear of failure, what if he died on the way over? Would he be comfortable? How is it going to go on the flight? Will I be able to reassemble the stretcher myself? What is going to happen to his abdominal abscess at cruising altitude? Fluid expands at lower atmospheric pressure, that could cause more pain and possibly rupture. What if he needs to poo?

A fitful sleep followed by an early start to the next morning, I woke up at 0430 as I had to be at the hospice by 0530 for a 0600 ambulance departure. I arrived at the hospice for last minute preparations. Medications had been prepared for the flight and I had plenty of pain relief, nausea relief and distress relief medications pre-drawn into labeled syringes.

Okay, everything checked off on the list. Deep breath, I’m as ready to go as I’ll ever be. Hmm, why can’t I stop pacing?

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Palliverse’s Greatest Hits from Oct 2014 – #getjakbak revisited – Part 2

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Photo by Jonathan Kemper on Unsplash

At 3pm on Friday afternoon, 18 hours before our departure time, I received bad news. The promised community raised funds had not come through. Was the trip to be cancelled because of a deficit of $3320?

I finished the phone call and took a quick walk around our inpatient unit, and talked to some of the staff about the funding problem. One of the nurses asked me what I was going to do. I really had no idea but for some unknown reason I replied to her, “Magic.”

I had 120 minutes to come up with $3320, at a rate of $27.67/min. What to do? What could I do? What was on the line was a dying man’s wish to return home to see his family. This was his final chance to try to get home, he had been trying to get home ever since he had arrived here months ago.

Who could help? Maybe a virtually community of practice? I went online and decided to launch my first ever crowd-funding campaign, asking people to pledge money towards the trip deficit. The original post can be read here. I emailed a link to it to everyone that I knew.

17 minutes later the first pledge came in, then another, then another. Drip by drip the pledges came in. $20, $40, $100, $200. Palliative Care people were keen to help including healthcare staff, administration staff. People from around New Zealand and Australia came to our aid. One of the other patients on the ward caught wind of what was happening and pledged $200 to help his fellow patient get home.

With only five minutes to spare we reached our goal, the trip was going to happen! I went to see our patient and his wife and told them that I would be seeing them early tomorrow morning for our trip back to the Islands.

Island-Man: Far From Home

Palliverse’s Greatest Hits from Oct 2014 – #getjakbak revisited – Part 1

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Photo by Rob Wicks on Unsplash

What a disaster I thought, as I listened to the referral. A 44 year old man had become unwell in the Pacific Islands and had been urgently transferred to New Zealand for assessment and treatment. He had an abdominal mass lesion which was extremely painful after having had massive weight loss over the previous two months. He had been a great orator and had been destined to be a future leader of his church. He was married without children.

He and his wife had come over two months ago and things had not been good at all.
He had been diagnosed with a large abdominal mass found to be cancer with spinal cord compression and lung metastases. The impression was that there was nothing that could be done medically for him, and that he should try to return back to the Islands as soon as possible as his condition would likely deteriorate quickly.

Travel arrangements were made for him and his wife to return back home in the following week, but he became acutely unwell before he could finish arranging his journey. A difficult situation, thousands of miles from home, with little in the way of family members or support locally. Displaced, stuck, and also critically unwell.

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I think therefore I am? – Mindful Room Reading

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Photo by Tyrell James on Unsplash

I’ve been practising Mindfulness meditation for the past seven years and I feel that it helps me to tune into my patients’ situations better. I still do my usual alcohol hand rub routine prior to entering each room, to bring myself into focus, to be present in the room.

I need to take in the whole atmosphere of the room, who else is in there, how are they interacting with each other. What is the emotional temperature of the space. It might be an inpatient room, an outpatient clinic, a hospital room, or at a patient’s home that I find myself.

A quick survey of the environment prior to beginning the assessment proper is useful. You look for extra equipment in the room. A commode chair can indicate difficulty with mobilising. Monkey bars or bed levers may confirm restricted independence. Is there equipment in the room, like oxygen tubing, oxygen concentrators, nebuliser or suction systems. Are there any hand held devices such as inhalers of sprays that the patient could give to themselves? Any walking aids? A sensor mat would indicate confusion and possible delirium. Not safe to transfer independently. Urinary catheter bags and tubes, and other drainage devices.

With observation alone you can find a lot of information, even before speaking to them. All of the above is assessed within the first 30 seconds of meeting someone. You also check out their visitors at the same time.

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I think therefore I am? – Milestones

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Photo by Towfiqu barbhuiya on Unsplash

There is something about the human spirit, some amazing inner strength that people have that allows them to hold on for special occasions. Two major milestones for people are Christmas Day and New Year’s Day. Out of the past ten years I have worked 8/10 of the New Year’s holidays. What usually happened was that no matter what spiritual belief people had they would likely hold on for Christmas Day, and possibly for New Year’s Day and then we would see a large number of people dying once they had achieved their milestone(s.)

Sometimes it can be living through their wedding anniversary, or beyond a loved one’s birthday.
People often will try not to die on a significant other’s birthday, so that the birthday will not be spoiled from thence on.

How does a comatose person even know the date let alone know what the time is? Somewhere deep inside ticks a very accurate body clock? People may be holding on for special occasions such as the wedding of their child, or grandchild. Or it might be the birth of the newest family member.

In Aotearoa New Zealand a lot depends on the national religion. People will hold on for the Rugby World Cup – the Rubgy League World Cup, not so much.

How can a person sense their environment when they physiologically have been made insensate?

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Palace of Care – Late referrals to palliative care are still common

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Photo by Aron Visuals on Unsplash

We had only received the referral the day before. Our nurse went out to see the patient and found him to be likely dying, suffering from pain and great distress. His wife who had been a registered nurse for almost 30 years was still talking about taking him into hospital for further treatments. They were persuaded to come into the hospice by ambulance.

The junior staff had seen him and asked for me to see the family as well, as they just couldn’t get the point across. They thought that he was actively dying, but his wife and daughter were still talking about going into hospital for active treatments, whatever was available.

I walked carefully into the tension of the room and noticed that the patient was breathing heavily, was not able to respond, but otherwise looked comfortable. His daughter was breathing heavily, unable to respond because she was crying, and looked uncomfortable. His wife was breathing quickly, responded slowly to questions, and her discomfort showed on her face.

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Bedside Lessons – 19. Let him cry

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Photo by Tom Pumford on Unsplash

He had asked to talk to us away from the hospice room where his wife was sleeping.

The trainee specialist and I led him to the patient lounge room down the corridor.

We all sat down.

We talked about how his wife was dying, how he was actively supporting everyone else in their life. Especially their three teenaged children, who were barely coping with the pending loss of their mother. He said that he had to be strong, that he would get them all through it…

The floodgate of his face broke, he curled up in pain, and the torrent of tears was released. The trainee reached for the box of tissues, and for his shoulder, and started to speak.

I subtly raised my hand to stop her from saying anything.

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Palace of Care – Traffic Conditions

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Photo by Erik Mclean on Unsplash

Metastatic cancer deposits in the abdomen can act like speed bumps on a road, slowing down the traffic of the gut, that’s why there is a greater tendency towards constipation. As these cancer deposits grow they can make things worse and if they are big enough can cause a roadblock, a bowel obstruction. The gut traffic will try to push through the roadblock but cannot do so, this can be painful, and will lead to reversal of the traffic flow, vomiting.

One of our treatments involves loosening up the roadblock with corticosteroids, they sometimes can decrease the swelling and inflammation surrounding the cancer deposits.

We have medications which we use to try to push harder through the roadblock – pro-kinetics which increase gut traffic.

The gut’s job is to digest food, and it produces around 2-3 L of digestive juices every day. We have anti-secretory medications which can reduce this production, helping symptoms by decreasing the volume of gut traffic.

There is a physical treatment which can be considered but which is more uncomfortable and invasive – the nasogastric tube. A tube inserted through the nose, goes down the throat and into the stomach, providing an alternative route for the vomit to leave the stomach – A detour.

Sometimes the roadblock/obstruction can be overcome, but a lot depends on the driving conditions as well, the overall health of the countryside – the person’s general health status.

If only there was a traffic forecasting system or GPS system that could help us to tell how the journey ahead will be. This does not yet exist with the current state of medicine and technology.

Despite the destination being the same, each individual trip may be completely different, and we can still modify try to modify the quality of the experience.

Please drive carefully if you are journeying on the roads during the holiday season.