Sunday, 31 January 2010

Gavin: A mistake...

Chemo is nasty. Derived essentially from plants, it attacks the actual DNA of your cells, causing some to die and some to become suicide agents, killing other cells they come into contact with rather than multiplying into cancer cells. It isn't clever enough to only target cancer and therefore has an effect on the whole body causing, amongst other things, hair loss, leaking kidneys, heart and blood pressure issues and an extremely serious compromise of your immune system. Sonny is chasing shots of chemo with various drugs that help these side effects. Then more drugs to stop the side effects that those drugs cause. Homeopathy this ain't.
Chemotherapy has to be administered by a nurse who is chemotherapy qualified. Before administering the drug, two nurses have to check hospital numbers, name and date of birth regardless of whether they've looked after Sonny for the last month or not. The chemo is only made up the same day by the cytotoxicity pharmacy to avoid it falling into the wrong hands and arrives on the ward an hour before infusion. The chemo nurse has to wear a mask and gauntlets to administer the drug and double check the rate of flow (how fast or slow it 'drips' into his body) with the other nurse before turning on the machine. In short, every step is taken to protect the patient from what is essentially, DNA poison.
Last night, despite all this, the pump was set to a flow rate less than half of what it should have been in a mistake by the two nurses. Four hours of chemo would have turned into 10 hours. Which means that the chemo would expire and be useless. The second set of chemo, given straight afterwards, would also expire and be redundant.
The night nurse, who we love, spotted the error from the day staff and began trying to rescue the situation. To put this into context (and trust me, only by living this for six months would we ever understand the ramifications) you can't just up the flow and hope its alright. Modifications have to be authorised by doctors who need to get that changed on the system by pharmacy who need to get that approved by cytotoxicity. This is all done across different departments in the hospital on an electronic system that will ensure the same mistake won't happen again. All this was happening at 1am.
The nurse worked wonders. The flow was adjusted to squeeze it in just under a 6 hour cut off point. The doctors arrived to rewrite the protocol so pharmacy would allow the second drug to be administered (and to change when it was made up for the next coming days). Today we have started just an hour early (the chemo needs to be given in alignment with a 24 hour cell cycle to be effective) which manages to readjust the mistake and get everything in under the prescribed time frames.
We have had apologies from one nurse and tears from the actual chemo nurse. We have been sat down with a doctor in a private room to explain what has been adjusted and to thank us for our understanding. Our consultant has been called on his Sunday off and will talk to us tomorrow. An incident report has been filed which will have to be followed up. Two uninvolved nurses have come to apologise for the situation which I'm not sure is a show of solidarity or to separate themselves from the mess. To put this into context, if the flow was incorrectly adjusted up instead of down, he would at best have suffered severe side effects and worst, organ failure.
It's wrong. We trust our consultant and the hospital immeasurably but in reality the life of our little boy is in the hands of nurses who are paid peanuts for the responsibility they hold. Of course, they will make mistakes at work because everyone does, but when we make mistakes the printer jams and we laugh about what twats we are. The bottom line is there are severe failings in the management of a hospital even as high profile as GOSH due to under resourcing and over work. I'd love to finish this off by telling you how my anger at the situation has bought about wholesale reform. But unfortunately that will not change until those controlling the budgets realise the enormous pressures the nursing staff are under in life saving situations.

1 comment:

  1. Bessy went to Kids Club for the first time tonight and when picking up, I arrived to a beautiful scene of an Yvonne organized craft session for the 14th!
    But the reason I'm writing this is just to say, that whilst waiting for Bessy to finish, I had a lovely and extremely witty chat with your Ruby, who looked very very happy in her art making. 2nd top is on it's way Ruby!

    P.s.I didn't ask who the creation was for though!!!