It's 7.30am and I'm rushing on to the ward five minutes later than anticipated, having left an unhappy child at nursery.
Looking at the unit, I note two of the six beds are empty -almost unheard of on a Thursday night. However, during report I learn that it has been hectic. Two teenagers have been admitted from a 'rave' with Ecstasy poisoning. One is ventilated in ICU and the other is here on the unit, pyrexial and tachycardic, but stable. We are also due an admission from casualty -Jim Harper, a 35-year-old man who has taken a paracetamol overdose. Following handover I introduce myself to Maisie Field, one of my allocated patients, before the admissions arrive.
Ms Field is old and frail and has obvious self-neglect. She had taken her antidepressant tablets, amitriptyline, and had been found at home by her husband, unconscious and fitting. Initially she had been intubated and ventilated in ICU.
Now, two days later, she is in the recovery phase, but still a little confused and agitated. She avoids all eye contact and refuses to speak to me, staring silently at her uneaten breakfast. Her husband arrives. He tearfully describes her decline over the last few months -her lack of interest, forgetfulness, wandering at night and then complete withdrawal, culminating in the overdose. I reassure him and offer him the chance to speak to our psychiatrist.
I finish documenting these findings as Mr Harper is admitted from casualty. I assess him and complete all the paper work as the toxicology laboratory phones to say that his paracetamol concentration is 'toxic' and he requires treatment. I draw up the antidote and contact the senior house officer.
Another of my patients, a 76-year- old man who had ingested 40 of his wife's temazepam tablets a few hours previously, appears to be deteriorating. His current Glasgow Coma Scale assessment is now three and he is not responding to painful stimuli. His cardio-respiratory monitor shows he has a respiratory rate of eight breaths per minute and an oxygen saturation of 90% on air. Blood gases are taken which indicate he has a respiratory acidosis. I contact one of our clinical toxicologists and we agree that fumazenil 0.5 mg intravenously should be administered immediately.
He becomes more rousable, his respiratory rate increases to 13 breaths per minute and his oxygen saturation progresses to 97%. On rechecking his blood gases, his acidosis has virtually resolved.
The consultant clinical toxicologist does a ward round, but no one is medically fit for discharge. I manage to drink half a cup of coffee before the booked admission arrives. He is a farmer who has been referred by his GP for investigation of chronic exposure to organophosphorus insecticides. He regularly uses sheep dip and has been experiencing mood swings, insomnia and muscular aches and pains for several months.
The consultant psychiatrist arrives on the ward and we go to assess Ms Field. She remains silent. After going through her history, he makes his assessment, which suggests she may have depression with pseudo-dementia. Although she is recovering, her depression is severe and she will require in-patient treatment at the local psychiatric unit.
Two other patients are reviewed and deemed psychiatrically fit for discharge. At the end of the round, I liaise with the psychiatric hospital and the community psychiatric nurse and transfers are arranged for Ms Field following her medical discharge.
Meanwhile casualty has a 21-year-old man who claims to have consumed a spiked drink the night before. He presented fitting and then had a respiratory arrest. The admitting team wants a drug screen performed. I take down some details, offer some advice and explain that we may have a bed available later. I then put them through to the toxicology laboratory. The rest of my shift passes quickly and I even manage to fit in a formal teaching session on blood gases for the student nurses.
The enjoyment of working on a unit like this is that you gain excellent clinical experience and are involved with patients from a variety of backgrounds who have a range of problems. In addition to patients who have taken an overdose, I look after patients withdrawing from alcohol and other substances and those with occupational diseases such as lead poisoning. I have also come to know several patients who often ring up for advice or just to talk.
I leave having seen one patient with a brighter view on life and feel satisfied, knowing that I have actually helped to make that difference. The patients' names have been changed