Theatres, Surgeries and Paediatrics

This week, I have finished my second week in my children's placement. It has been so interesting and once again I feel I have learnt so much. My mentor has been great in allowing me to experience different things in my placement. This week I have been assisting in admitting patients and discharging them. I have been able to follow patients through, from admission, preparation for surgery, anaesthesia, the surgery, recovery, return to the ward and then discharge. Seeing the patient's journey has been incredible. However, it has been hard getting used to having such a short period of time with the patients. I have worked in the community a lot, and it is something I enjoy. I like getting to know the patients / clients / service users and building up that relationship. So having patients come in and leave within a matter of hours takes some getting used to! 

This week I have spent time in the theatres being able to watch some paediatric surgeries. I have seen dental extractions, ear, nose and throat surgeries and finally an appendectomy. I have loved it! I was warned that they have had several nursing students faint in theatres and that often its because some people have not eaten. So I was able to grab a bite to eat, then away down to theatres. My mentor contacted the surgeon to see if it was okay that I observe, and permission was gained from the child's parents. I was then shown where to change into my scrubs and then clean up ready for theatre. I was told to not touch anything blue or green, as these were sterile and would compromise the surgery.

In each surgery I observed the patient going under the anesthetic. With children this is very daunting for them. If they go under scared and upset, then they can have a tendency to then come back round upset too. The children were placed under via mask and then injection. Depending on the child they would find it easier with one or the other first.  Once they were placed under, their airway was supported and they had a endotracheal tube or laryngeal mask.  A laryngoscope may be used for placement of a endotracheal tube.  Airway management is the responsibility of the anaesthetist. 

Airway management:

Endotracheal tube

Laryngoscope

Oropharyngeal airway

Laryngeal mask

My first surgery was a tonsillectomy and adenoidectomy. I was able to look down the viewfinder of the microscope as the surgeon was operating as he explained what he was doing and what I was seeing. Utterly fascinating! I was fortunate to see them removing ear wax from a child's ears and then removing the adenoids and tonsils.  This is a great surgery and was somewhat straightforward. Of course not all surgeries like this are straightforward.  The surgeon informed me that although it looked simple, it can be the case where it is the exact opposite.  Never be afraid to ask questions, the surgeon was so helpful and was more than happy to answer questions. 

Enlarged tonsils.

My second surgery was dental extractions where children were having teeth removed. Although this sounds like it could be a simple trip to the dentist it was far from that. One child had some teeth removed and a gap left where the incoming tooth could move into. Then another child had to have their hard palate cut back and to the side of the maxillary labial frenum (that piece of muscle under your top lip at the front of your top teeth) cut to gain access to the cavity beneath the nose at the roof of the mouth. This was a longer and more complicated surgery but was good to see how this was done and the knowledge of the dental surgeon. Again the surgeon was able to explain each stage to me and show me what was involved. 

My third surgery was an appendectomy. This was a little longer than the first two surgeries and a little more intricate and so interesting! Not recommended if you are somewhat squeamish.  I watched as the cut was made after they had felt to see where the appendix would be. The child twitched so was put further under anaesthetic. This can be due to nerves and the body not being fully relaxed due to the adrenaline that will be surging through the body beforehand with the nervousness the patient will be feeling. 

Once the cut was made, the layers of tissue, and the peritoneum were cauterised, then the appendix was located. Once this was located its blood supply was tied off. This was then removed and checked before being placed in a specimen pot to be sent to pathology.  The various layers were then sutured back together. Suctioning was used at various points and the area washed with saline to ensure it was clean.  The overall incision was a couple of inches and the surgery will have improved the quality of life for the patient.  It was remarkable to watch. I don't however recommend if you can get queasy! Especially at the smell of the cauterising of flesh, that is something you will remember! 

Once the surgeries were complete I was able to watch the patient being brought round from the anaesthesia. The nurses in the recovery room monitor the patient, note the patient's observations and ensure everything is as it should be.  The patient will not be sent there if the anaesthetist is not happy.  Once the patient comes round and everything is okay, then the patient's family are called in. Everything is recorded and even the machines monitoring the patient will give a print off for the patient's records. It is so important with anything now that it is all documented. As they say, if it isn't written down it didn't happen! 

If you get the chance on a placement, I do recommend asking if you are able to, observing some surgeries.  They are incredible and just reaffirms how amazing and intricate the human body is.  And underneath it all, we are all the same. 

A Not So Quick Trip To The Dentist

So this week marks the end of week 3 of placement.

I have again done a lot and some days not so much. I have laminated things, I have designed tables for patient information. I have answered phones and replied to emails.

As I am on placement with a third year I have learnt a lot from them. But in some ways this puts my learning to a disadvantage as they get them to do a lot rather than myself. So I have had to speak up and offer to do these things as well. The staff don't want to rush me or pressure me but I have said with my previous experience I want to be pushed rather than just guided.

This has meant that I have learnt from the student but I have also had to say I want to learn more.

Luckily enough though my mentor has been great and I have had plenty of opportunities. 

This week I have been able to go to the day care facilities, I have been to the dentist who specialises with patients with learning disabilities and I have been able to witness how resettling goes for our patients who are moving to the community and I have had my midway review. This is a discussion between my mentor and I and how we believe my progress is coming along or indeed if I'm not progressing.

My visit to the dentist was definitely eye opening this week. I was lucky enough to have the patient to consent to me being in the room during their treatment and the other health care professionals (HCP's) were more than accommodating. I was able to see the dentist, the dental nurse, the learning disability nurse who works in the dental department and the doctor who is there to oversee things and to administer the medications needed. 

The treatment was, what would to be to you and I, a basic check up and maybe a scale and polish. As this patient was very nervous and unsure of the dentist, the protocols involved in the treatment were quite extensive. The patient has a learning disability, and as such is unable to consent to treatment due to lack of capacity and understanding. This means that the patient's next of kin and carers had to be involved as well as others in a multi disciplinary meeting to ensure that the treatment is in the patient's best interests. Then after the meeting and the outcome has been decided, the various HCP's then have to decide how the treatment will take place and when. 

The patient is monitored and the procedure is explained to them in a way that they may understand and will reassure them. The amount of paperwork and meetings involved for this patient to have a dental check up is quite extensive. During the treatment, the patient's observations are taken and monitored. The patient is given a small amount of sedative to relax them and make them feel at ease by the doctor who is present during treatment. The dentist and dental nurse then work in tandem to complete the treatment, while myself and the specialist learning disability nurse continue to monitor the patient, assessing their respiratory status at all times and reassure the patient and monitor for any signs of distress. The patient's carer meanwhile, waits in the waiting room. The doctor was able to explain to me the medications used and why they are used for patients that are nervous of the dentist. As the medication is a light sedation that has been decided in a multi disciplinary meeting then the patient is deemed to be at risk but a small one. As the patient has their check up and plaque removed, it is thought necessary that the patient again be referred due to a tooth possibly needing further treatment. This will again involve a referral and perhaps several more meetings before it is decided whether to continue further treatment is in that patient's best interests. Health, age, mental status, ability to consent, their capacity and next of kin's opinion is all taken into consideration within these meetings. 

As the patient received a small amount of sedative, they are given medication to counteract this once the treatment is complete. They are monitored within the dental surgery for a short while before they are deemed okay to leave. The venflon is then removed and the patient is again observed for any signs of tenderness or allergic reaction to anything used in the treatment.

Different sized venflons

Before the treatment can even go ahead, the patient's medical records are scrutinised for anything that may deem the treatment unnecessary or that may affect the treatment whilst it is ongoing, such as epilepsy and any medications they may be on for that. 

So for a check up for you and I that may take perhaps ten minutes. this treatment took just over an hour. 

So next time you take a trip to the dentist, please try and remember that even if you feel a little nervous, you are able to reassure yourself and understand what is happening. For someone with a learning disability, this can be the most stressful time, full of anxiety and worry.  It is remarkable the process that goes into ensuring someone with a learning disability can access dental care.  If you happen to care for someone with a learning disability, professionally or personally, then please remember dental care is very important. Dental care is essential, and if someone has toothache or any cavities, this can impact on their diet, their self esteem, their behaviour and perhaps their relationships.  Even if a person has no teeth, gum care and pallet care are still as important. Oral cancer and differentiations in pallet can indicate a multitude of things. Thus the dentist will still require a visit! 

This week? Remember communication isn't just speech, it is your body language, it is music, games, sexual activity, symbols, gestures, objects of reference. It all makes a difference to that person's day.