Benzos and Bowel Sounds

Emily Hurt @EmilyHHurt

At Lancashire Teaching Hospitals NHS Foundation Trust, a clinical librarian has shadowed a ward round on the Critical Care Unit every two weeks for the last three years.

The idea came about following discussions between the head of the Library and Knowledge Service and a Critical Care consultant. The consultant wanted to provide support for junior doctors who were training on the unit – facilitating the link between what they were learning and ‘the literature’. The clinical librarian joins the ward round and listens as patients are presented to the team. They make a note of any hot topics – unusual conditions, queries around medication, specific co-morbidities etc. Sometimes the consultant leading the round will specify topics, and frequently the clinical librarian will ask for clarification on what has been discussed or check spellings of conditions or medications. Following the ward round the clinical librarian carries out quick searches for relevant articles for each topic, usually on PubMed and sometimes using NICE Evidence Search or online resources like Life in the Fast Lane. These references are then put into a blog post which is published on a Wordpress site: Critical Care Evidence Update . The number of posts per round varies but is normally between two to four.

As the blog posts are just signposts to relevant literature and not a comprehensive topic review, there is no summary or introduction, just references and links to full text where possible. The type of references chosen will depend on the topic and how much literature is available. Systematic reviews or articles that provide a good overview of a condition are useful, but sometimes there is little written on a topic and case studies and basic review articles come into play. Articles with full text availability are preferable.

Once the blog post has been published, it’s automatically tweeted from the library’s twitter account and email followers will get a notification that there is a new post. The clinical librarian also posts a link in a Critical Care WhatsApp group.

So that’s the logistics of it, and re-reading it all in black and white it sounds very straightforward. But as with most things, it’s not quite as simple as it seems. 

Read the Critical Care Evidence Update here:

I’m Emily, the clinical librarian who has shadowed the ward round for the last 10 months, and as a non-clinical person in a very clinical environment. I was initially very apprehensive about shadowing. Would any of the consultants know who I was? Would I see all sorts of gory injuries and people going in to cardiac arrest every five minutes? Would I find it distressing? And most importantly, how on earth would I understand what they were talking about? I’d like to share my experiences, partly to demystify the ward round process, but also to explain what I get out of shadowing and how I find it rewarding on lots of different levels.

Would any of the consultants know who I was?
The answer to this is no, a lot of the time they wouldn’t know who I was. And neither would most of the juniors and specialist trainees who were on the round. But that’s easily overcome with a quick, ‘I’m Emily from the library and I’m here to shadow ward round if that’s ok.’  Followed by a brief summary of the blog and its purpose. I’ve never been turned away from a ward round, although sometimes it’s been obvious the consultant leading the round hasn’t really known what to do with me. One actually did ask, but I explained I just observe and seek a bit of clarification at the end if necessary. Once they’ve worked out that I just quietly follow and make notes, they’re put at ease. Several will now proactively identify topics for me and take time to explain things at an educated lay level, which helps enormously when I get back to my desk and start searching.

Would I see all sorts of gory injuries and people going into cardiac arrest every five minutes?

In short, no. The majority of patients on the unit are sedated and if they have any major trauma injuries they’re all covered with dressings and bandages. By the time most patients reach the Critical Care Unit they are relatively stable, although often very seriously ill. No-one has crashed while I have been on ward round. One person did go into atrial fibrillation, which caused a little alarm, but it was soon under control with a variety of drugs administered as we were at the bedside. 

There have been some sights which I have had to get used to. The unit has a lot of neurological patients and many have had surgery resulting in drains or intracranial pressure (ICP) bolts being placed in their head, which can look alarming. Patients can often be a funny colour, for a variety of reasons. Some are very pale, others yellow as they have pancreatitis or liver problems, some are red as they are have high temperatures. Often patients have visible bruising due to problems with their blood or invasive procedures.

Would I find it distressing?
At times, yes. When people are sedated they aren’t always soundly asleep and if they are in pain they will sometimes grimace, twist and turn in their bed and cry out. The staff try their hardest to make sure that patients aren’t in pain, but sometimes the balancing act between different medications can make it difficult to achieve this. 

There are often patients who for one reason or another are at the end of their lives and critical care can no longer do anything for them. It is upsetting hearing patients discussed in this way, but it is a normal part of the unit, as not all patients make a full recovery. There is lots of work that goes on to ensure that patients who are nearing the end of their lives are as comfortable as possible, and if circumstances allow they sometimes return home rather than remain in hospital. Others are surrounded by friends and family. Often it’s the absence of people that can be upsetting – an older man who lived in a nursing home had come in with a bleed on the brain and was on artificial life support. He had been certified brain dead and treatment was about to be withdrawn, and there was a discussion on the ward round about next of kin. He had no named contact on his notes and the nursing home said he had no friends or family to notify. To me that felt sadder than the passing of those whose beds are crowded with people.

People’s stories can also be distressing. When looking at a patient in a bed who is calm, sedated and intubated it can be easy to detach the person from the patient. They are a condition, a set of observations, a list of medications. But sometimes the ward round involves discussing the person as well as the patient – they have children aged 7 and 14, they drink three bottles of wine a day, they were found on the floor of their flat after two days, they jumped from a building, they’re in an abusive relationship, they weren’t wearing a seatbelt. Lots of stories involve alcohol or substance misuse and the sadness is amplified as these admittances to critical care could have been prevented, if only things had been a bit different for that person.

Would I understand what was being discussed?
The honest answer to this is no, a lot of the time. But I don’t need to understand everything in order to do my job. In the same way that I don’t need to be a dermatologist to be able to do a literature search on the use of methotrexate in treating psoriasis, I don’t have to be a nurse or doctor to get the information I need from the discussions on ward round. I have become familiar with the common themes that present with most patients:

Breathing – can they do it by themselves? If they can’t, are they on the right sort of machine? What steps are being taken to get them off the machine? What does their chest sound like?
Sedation – are they on any? Do they need more? Could they have less? If they’re getting less, are they waking up properly? If they’re alcohol dependent, are they on the right drugs to make sure they’re not suffering from withdrawal?
Bowels – have they pooed? What sort of poo was it? If they haven’t, what steps are being taken to make sure they do?
Infection – are they showing any signs of infection? What tests have they had to look for infection? What potential sources of infection do they have?
Fluid – have they got lots in their body or not enough? How much wee are they producing? How are they being given fluids?
Nutrition – are they being fed? How? Is it getting through their system properly?
Drugs – What are they on? Can any of them be stopped?

Regardless of the condition the person came in with, these are all things that will have an impact on their stay in critical care. Once you are sedated and lying down, your lungs are at risk of packing in, your bowels could stop functioning and result in a perforation, your kidneys can start to struggle and you could end up with a life threatening infection from a number of sources. So while the care that the unit is providing is vital to keep you alive, it can also cause extra problems for you as well.

I still don’t understand the reams of test results that are discussed, and there are many, many abbreviations used that are still unfamiliar to me. But each ward round brings new learning and my vocabulary continues to increase.

What do I get from all of this?
Unfortunately the shadowing has been suspended for a short period, as our clinical librarian team is at capacity for literature searches and although the blog is valued, it isn’t a core service. When it is running, I look forward to shadowing ward round each fortnight and it’s currently one of the aspects of my job that I enjoy the most. It’s expanded my general medical knowledge and given me a basic understanding of the care provided in the unit. Searching for relevant literature is still slightly trial and error, as the research base for critically ill patients is not expansive by any means. But I think I have honed my search skills as a result of putting the blog posts together. 
I’m definitely not an embedded part of the team on the unit, but as a result of being a regular presence I am more of a familiar face and I think there is a better awareness of library services amongst all staff. Although the blog is targeted at medical trainees other professions have used it, and the dietitians on the unit are particularly keen on it. They wanted to set up a journal club and asked me to come and facilitate the first session. I’ve also had nurses and trainee Advanced Critical Care Practitioners (ACCPs) approach me for information skills support.

It’s made me think more about the information needs of patients too. They’re definitely not represented in the blog posts, as the literature I find is solely in the interests of medical professionals. I do try to add in articles from a patient perspective where available (for example experiences of mechanical ventilation), but again the material available is thin on the ground. I would love to develop an information service for patients and their significant others, but that would require a lot of work and our LKS doesn’t currently have the resource to do this.

Late last year I put together a brief survey to try and capture some of the impact of the blog, and got a consultant to send it out to medical staff. There were 18 responses, mainly positive, and the next step is to collate the answers and think about where we go from here. I’m keen to expand the blog so that it’s for all members of staff on the unit, and am planning to contact leads for AHPs and nurses to work out the best way to do this. In the meantime when our literature search pile has become manageable again I’ll resume fortnightly shadowing, and try and provide that link between the patient in the bed and the research that helps future consultants learn how best to treat them.

Victoria Tredway produced a video showcasing a similar service at Wirral University Teaching Hospital NHS Foundation Trust and this provided the inspiration for the service development.