My last few posts have been what some may define as moany/dramatic and that’s because some blood and guts have hit me in the face (almost literally but mostly metaphorically!). My fiance, who’s been struggling with chest pain for months, is finally being treated for a collapsed lung (hence the title of the post) and after many trips to A&E and appointments and x-rays he is still stuck in a hospital chained to a bed by a tube in his chest. A ten minute painless, yeah right, procedure turned into a two-hour long, morphine endured, knitting needle stab of the lung. It was the most horrific thing I have ever watched and am blown away by the way my fiance dealt with the pain, bravest man I know – just saying!

In between the working and the visiting, the worrying and keeping everyone up to date these last few weeks, I am exhausted (hence the coffee!). I have found it really, really hard and have been dealing with things myself which were deep, deep from my past. Through this I have realised that maybe I can see God in this chest drain too.

At some point my fiance’s lung collapsed, we’re not too sure why, and for months he lived with 70% lung function. He managed, but his life was affected by the things he couldn’t do and the constant pain he was in. The day came when the drs decided enough was enough and although it was incredibly painful they knew they had to get in there and fix the issue.

Had I been living with 70% function as well? Had my past experiences of illness, hospitals and loosing my loved ones started to affect my everyday life in the things I couldn’t do and that pain that I was in? YES. In his astounding wisdom I believe God has been using the physical situation of my fiance’s illness to emotionally do the same thing to me. To get in there and fix it for me, and even though I am in pain I truly believe, and can see, that God is sorting me out!

Wow – I mean talk about practicing the two become one thing before we are even married!

God is SO GOOD and although last week I was posting about His goodness without understanding it in regards to this situation now I think I can see further than my humanness would choose to, and I’m seeing into the Kingdom of God waging its battle against the darkness in my life.

THIS is why I’m praising!

Does it feel good having a chest drain? No. Does it feel good facing old wounds? No. Is it worth it? Yes. My God is so very good.

photo credit: <a href=”http://www.flickr.com/photos/cataniamichele/2855661699/”>Michele Catania</a> via <a href=”http://photopin.com”>photopin</a> <a href=”http://creativecommons.org/licenses/by-nc-nd/2.0/”>cc</a>

The things I found good about having scoliosis surgery were:

1. Waking up from surgery the effects are immediate. When you first stand up you feel taller and your back is straighter so, it is never a pointless surgery! 
2. The reduction in pain- now for me this wasn’t such a big thing because I had my operations when I was so young so, either I wasn’t in so much pain or I don’t remember the pain prior to my ops.
3. Having all my ops in a children’s hospital- I didn’t think this was a big thing at the time until I got moved to an adults orthopedic hospital and the atmosphere was totally different so different that I couldn’t ever see myself having an op there. The staff at Great Ormond Street Hospital are amazinggg and I would recommend GOSH to anyone!

The bad things about surgery would have to be:

1. Having my wound dressing changed! WOW I used to hateee it! I have never been a fan of people touching my back and after my first operation I used to take off the dressing myself which was just less stressful for me
2. Having the morphine pump- As amazing as morphine is it used to hurt so badly when it would go through my veins
3. Having my wound and chest drains removed and also the nasogastro tube- the wound drain wasn’t so bad but the chest drain was so painful I still remember the pain clearly. The nasogastro tube was more discomfort than pain.

In terms of regrets I think the main one is not really understanding what was going on at the time. I wish I had asked questions but at the same time I didn’t know what questions to ask. I also wish I had taken more pictures and videos because as much as its something I want to forget its something I also want to remember because its a process I had to live through to get to where I am now. I also wish I had more control over the situation. Had I known what was going on I would have still willingly started my operations at the age of 9 but I would not have agreed to have had my spine fused at 14 because now even if I want more correction that’s not an option because my spine is fused

This is my little insight into my various surgeries! Until next time!

N.M x

Twitter: @spinetospine

A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!

You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.

This is his supine CXR…

EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….

CT-Chest is performed….

Now, what to do ?

I read a similar case by @keeweedoc … “Conservatism Fails” and found myself looking for evidence. I believe the following paper adequately challenges the old dogma that ‘traumatic pneumothoraces mandate tube thoracostomy’ and empowers us to safely observe the patient with blunt traumatic occult pneumothorax.

The paper:

Blunt Traumatic Occult Pneumothorax: Is Observation Safe?— Results of a Prospective, AAST Multicenter Study

Moore, FO et al. J Trauma. 2011 May;70(5):1019-23; discussion 1023-5.

Prospective, observation, multicenter study.
Comparison between ‘successfully observed’ & ‘those who failed observation’ for blunt traumatic occult pneumothorax.

588 OPTXs (79% initially observed, 21% received immediate tube thoracostomy)
Only 27 of 448 OPTXs failed observation.

 Factors associated with failure of observation.

• Respiratory distress (OR ~6)
• Positive pressure ventilation
• Initial size of OPTX
• Progression of PTX on CXR (OR ~70 !!)
• Associated haemothorax

Interestingly; pulmonary contusion and increasing no. of rib fractures was not associated with failure. PPV to facilitate surgery alone, was also not predictive of failure. No patient in this study developed tension PTX in the observation group.

The case continues…

He is admitted under the trauma surgeons and his pain well controlled on a fentanyl PCA.

Whilst they initially elect to observe his PTX, 4-5 hours later he becomes more dyspnoeic & is found to have worsening subcutaneous emphysema…..

I’m interested to know if this changes your practice ??

Chris.

Though I was feeling quite drained at the beginning of the morning (related to insomnia – sound like a nursing diagnosis?), today’s shift was pretty good in my opinion. It’s good to be back on AM shifts!

Today on the menu during the shift:

• Looking after patients under the supervision of my preceptor – Though I didn’t do all cares independently, it was good to start small and simple. And this way, I felt like I was truly developing therapeutic relationships by getting to know the patients under my care : )
• Doing daily cares for my patients – Pretty self explanatory I think~
• Observations – I also felt that during this shift, I was able to practice doing more of these, which is always a good thing! More so with doing observations manually; even though they take longer, they can be more accurate (my goal for next time is to consider doing both – to compare my results and see how accurate I am). Also noting here that I was observed by my tutor in doing observations – observations all around!
• Medications – As I have been doing over the past couple of weeks, today was another day of helping to prepare and administering medications for patients under the supervision of my preceptor (and watching while she administered IVABs (intravenous antibiotics) since student nurses aren’t allowed to deal with IVs, at least in second year). I was allowed to prepare the IVAB, just not the actual administration itself. But that can wait till next year. (The use of IVCs made me think about phlebitis – which is inflammation of a vein due to a blood clot. the facility uses a phlebitis score to assess the degree of inflammation and appropriate actions to take; it seems that a grade that is 2 or over (up to 5 I believe?) means that the IVC needs to be taken out. Apparently a grade 1 phlebitis score equates to the size of a $2 coin. Anyway… I’d like to find out more about phlebitis) : D
• Documentation – This included observations, nutrition charts where appropriate and patient progress notes. Though not directly related to documentation, I did handover for one patient during this shift – this would be the second time I have done so ^ ^ (It’s probably not that noteworthy, but handovers at the facility are carried out by tape recorder, meaning that people will hear my voice sounding funny, and the additional fact that my voice will remain within that device for an undefined time. In my opinion, when I first heard myself through the recorder, I thought I sounded really high-pitched.)
• Following the MDT – This was an interesting experience for me, and it would have been good to start doing this earlier. It’s good to hear the input from the team to know how the patient is doing. When the team visited one of the patients, they listened to her breath sounds, and I wished that I had my stethoscope with me at that point in time so that I could also listen to her breath sounds. After all, we as student nurses haven’t heard that much of a variety when it comes to breath sounds since we mostly practice on each other : D
• Observing the removal of a chest drain – This wasn’t for any of the patients under my care but I was interested to view this. The doctor removed the tube that was inserted through the back of the patient, and this tube was attached to a machine. I don’t currently have a good idea of chest drains, but my understanding is that they are used to remove air/fluids/pus etc from the chest. But yes, I shall find out more about that (together with phlebitis)~

That’ll be it for tonight. Quite a lengthy post in comparison to the usual. Got a few more things to do and then I’ll be having an early night fairly soon; need to catch up on sleep since I’ve been busy working on my care plan assignment (finished and handed in today! Hope that all is well~).

Next update will be tomorrow around this time or earlier/later : p

Please note the full drapes, gown, and sterile technique – Ward 3 now has a chest drain bundle to comply with, encouraging you to use sterile technique.