ENDOSCOPE EVOLUTION

The word endoscope comes from the Greek word endoscópesis, a compound word consisting of éndon, which means inside and scopeín, which means to watch carefully.

An endoscope is a lighted optical instrument, typically slender and tubular, that is used to get a deep look inside the body. Specialized endoscopes are named after their target organ.

Early physicians such as the Arabian, Albukasim (936-1013 A.D.), and later in 1805, Phillip Bozzini, were among the first to develop methods to examine body orifices. Throughout the mid 1800's, several scientists attempted to construct endoscope-like instruments.

The first effective open-tube endoscope was developed in 1853 by Desormeaux and it was used to examine the urethra and the bladder.

In 1868 Adolph Kussmaul tested a rigid gastroscope on a sword-swallower to establish the line from mouth to stomach.

Due to the limitations on flexibility, the patient had to be positioned in order that the gastroscope could simply slide down the oesophagus towards the stomach. It would then be rotated to visualize all areas of the stomach.

Rudolf Schindler (1888-1968), considered the “father of gastroscopy”, made incredible efforts to promote the use of gastroscopy as a diagnostic technique for gastrointestinal conditions.

Schindler was the brains behind the first ever semi-flexible gastroscope, created in 1931. He constructed the gastroscope in such a manner that the distal end could be rotated, while the proximal end remained stationary. This allowed easier access to all areas of the stomach.

The first fiber optic endoscope was invented by Basil Hirschowitz and Larry Curtiss in 1957, allowing further exploration of part of the small intestine and the whole colon.

From 1968 to 1990, there was an explosion in technical achievements that transformed the practice of gastroenterology. An example of a major breakthrough was the capability to see beyond the mucosa with endoscopic ultrasound. This period is considered by some as the “golden era” of gastrointestinal endoscopy.

The endoscopes used nowadays not only have improved in terms of image quality and patient comfort, they allow the insertion of different medical instruments that are key on diagnostic and therapeutic procedures.

As technology evolves, further developments can be expected in the endoscopy field, from robotic systems, disposable endoscopes, video capsule endoscopy, augmented reality and new imaging modalities, to endoscopy VR simulators for trainees.

                                            Endoscope Olympus GIF-H180

Sources:

-https://www.medicinenet.com/endoscope/definition.htm

-https://en.wikipedia.org/wiki/Endoscope

-https://pubmed.ncbi.nlm.nih.gov/9449087/

-https://pubmed.ncbi.nlm.nih.gov/22717798/

-https://heritageblog.rcpsg.ac.uk/2016/09/29/the-semi-flexible-gastroscope/

-https://link.springer.com/article/10.1007/s10620-013-2976-3

-https://www.medlikim.com/en/produit/endoscope-olympus-gif-h180-2/

-https://en.wikipedia.org/wiki/Endoscopy#Medical_uses

ENDOSCOPY

Endoscopy is the insertion of a long, thin tube directly into the body to observe an internal organ or tissue in detail. Its purpose can be diagnostic or therapeutic. 
These procedures are minimally invasive and usually performed through natural body openings such as the mouth and anus, these cameras can also be inserted into small incisions.

Endoscopy can be used to investigate different body systems: 

• Gastrointestinal tract: 

-esophagus, stomach, and duodenum (Oesophagogastroduodenoscopy, also known as OGD).

-small intestine (Enteroscopy).

-large intestine/colon (Flexible Sigmoidoscopy, also known as FOS, and Colonoscopy).

-liver, gall bladder, bile duct and pancreas (Endoscopic Retrograde Cholangiopancreatography, ERCP) 

-rectum and anus (Rectoscopy, Anoscopy).

• Respiratory tract: nose (rhinoscopy), lower respiratory tract (bronchoscopy).
• Ear: otoscopy.
• Urinary tract: cystoscopy.
• Female reproductive tract (gynoscopy): Cervix (colposcopy), uterus (hysteroscopy), fallopian tubes (falloposcopy).
• Through a small incision: abdominal or pelvic cavity (laparoscopy, also known as keyhole surgery or minimally invasive surgery), interior of a joint (arthroscopy), organs of the chest (thoracoscopy and mediastinoscopy).

Gastroenterology is the branch of medicine that focuses on the digestive tract, the gallbladder, liver, bile ducts, and pancreas. Endoscopy is often used in this specialty to diagnose or treat different gastrointestinal conditions. It can help identify ulcers, bleeding, celiac disease, blockages, inflammation, and tumors, and find the cause of unexplained symptoms, such as heartburn, abdominal pain, weight loss, bleeding, nausea and vomiting.

Ultrasound or fluoroscopy are often used in conjunction with endoscopy for, but not limited to, detailed imaging of the digestive tract and adjacent organs, and management of therapeutic procedures such as removal of gallstones from the bile duct, stents and dilatations. 

Capsule Endoscopy

It's a type of endoscopy done using a wireless camera that fits inside a tiny, disposable capsule that can be swallowed. 

The camera takes several thousands of pictures or a video along its journey through the gastrointestinal tract, these pictures and images help detect and diagnose different conditions.  ‌

It is commonly used to view the small intestine which is difficult to access using a traditional endoscope. 

Sources:

-https://www.medicalnewstoday.com/articles/153737

-https://www.digestivemed.com/blog/post/the-benefits-of-an-endoscopy.html

-https://www.webmd.com/digestive-disorders/what-is-capsule-endoscopy

-https://www.istockphoto.com/photos/endoscopy

INTENSIVE CARE

Intensive care medicine, also called critical care medicine, is a medical specialty that deals with critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes providing life support, invasive monitoring techniques. resuscitation, and end-of-life care.

All hospitals classify patients according to their needs. This helps them to provide the best possible care in the most appropriate part of the hospital and tailor their services to suit patient's requirements.Most patients who require Critical/Intensive Care services fit into either Levels 2 or 3.

LEVELS OF CARE

LEVEL 0

Patients whose needs can be met through a normal ward care in an acute hospital.

LEVEL 1

Patients whose condition is at risk of deteriorating, or that have been recently relocated from higher levels of care. Their needs can be met on an acute ward with additional advice and support from the critical care team,.

LEVEL 2 (ICU/"WARDABLE")

Patients requiring more detailed observation or intervention including support for a single failing organ system, post-operative care or those stepping down from higher levels of care. 

LEVEL 3 (ICU)
Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure. 

Patient's are admitted to intensive care because potentially reversible physiological crises threatens one or more body systems, and life. Some common reasons for a person to need intensive care include:

• a serious accident – such as a road accident, a severe head injury, a serious fall or severe burns
• a serious short-term condition – such as a heart attack or stroke
• a serious infection – such as sepsis or severe pneumonia
• major surgery

Due to this, the nurse to patient ratio is 1:1, nurses require specific ICU skills and medical rounds happen more often than in general wards.



Sources:
https://en.wikipedia.org/wiki/Intensive_care_medicine

https://www.bfwh.nhs.uk/our-services/critical-care/levels-of-care/

https://www.nhs.uk/conditions/intensive-care/

Intensive Care Nursing, A Framework for Practice, 4th Edition 2019, P.Woodrow.

Picture: https://www.statnews.com/2016/09/07/hospital-icu-modernize/

NURSING

Let's start from the beginning, What is nursing?

                            

The challenge to find a simple, workable definition of nursing remains. It’s long history and wide diversity of setting and action are proof that it is a flexible and dynamic activity, therefore complex to define. Castledine elaborated a simple definition based on nurturing back in 1994: "Nursing is nurturing people with their health-related experiences, problems and concerns".

He believed that there is more to the nature of nursing than any definition can encompass.

Other authors like Nancy Roper have used personal experiences to define nursing. She used three nursing procedures to illustrate different points: giving medicines as an example of the dynamic nature of a procedure over time and how it needs to respond to increased knowledge from research; how serving meals, on the recommendation of non-nurse researchers, was designated a non-nursing duty with disastrous results for some patients; and how the many interpretations of the nil by mouth regimen have caused malnutrition in postoperative patients. 

She states that beliefs about what constitutes nursing are not static, nursing policy responds to changes in a wide range of interfacing areas but she is convinced that there is a nurse-initiated core that concerns patients’ problems with everyday living activities. She believes that it is the core that enables nurses, even in their diverse practices, to speak with a united voice, particularly to those in power, so that nursing will be adequately financed and resourced to provide an ever-evolving, high quality, cost effective service.

In the table below there are the definitions provided by different official organizations and search engines nowadays:

Wikipedia:

Google gives a very simple definition, which is probably the most common understanding of nursing:

"The profession or practice of providing care for the sick and infirm."

All the definitions, except the one given by google, acknowledge the amount of different tasks and even roles that nursing involves and most of them agree that there is a core  common to all different specialties and forms of nursing.

Sources: 

-Castledine, G. (1994) A definition of nursing based on nurturing. British Journal of Nursing, 3(3), 134-135.

-Castledine, G. (1994) Nursing can never have a unified theory. British Journal of Nursing, 4(3), 180-181.

-Roper, N. (1994) Definition of nursing: 1. British Journal of Nursing, 3(7), 355-357.

-Roper, N. (1994) Definition of nursing:2. British Journal of Nursing, 3(9), 460-462.

-https://en.wikipedia.org/wiki/Nursing

-https://www.google.es/#q=nursing+definition

-http://www.icn.ch/who-we-are/icn-definition-of-nursing/

-http://www.who.int/topics/nursing/en/

-https://www.rcn.org.uk/professionaldevelopment/publications/pub-004768

TIME FOR CHANGE

I have used this blog as a learning tool through my journey in Nursing.

I remember wearing my uniform with pride, feeling so lucky because I was working in something that I loved.

But the uniform started to get heavier, the time spent with the patients decreased dramatically while paperwork, recording to "cover your back" or "signing for your life" took over. It makes you feel like the patients are your "enemies" and everybody is waiting for that mistake that you are going to make that will destroy your career, your life.

I am the kind of nurse that cares, that does all the training available and goes an extra mile for her patients, but it is not fair, what you are giving, for what you are getting.

The tolerated and systematic abuse from some patients and families, the long hours without food, breaks or without going to the bathroom, the dangerous short staffing levels, the unreal expectations and responsibility, the poor pay for the essential and hard job that nurses and carers do on a daily basis... these are just some of the reasons why I have decided to take a step back, a break, from Nursing. 

Weekends off, your family and friends, and your own health become difficult or even impossible to maintain. Doing further studies while working... well, you can imagine.

A profession so admirable, recognized by none but blamed by all when things go wrong. I just do not have the strength anymore, and its painful, and I am sorry.

To all the health care professionals that have ever worked with me, thank you, I have learned from each and every one of you, we have shared our passion for the job and supported each other, I will always look up to you.

To all the ones that I have treated, admitted, informed and a long etc, I hope you noticed my devotion and believe me when I say that I truly did my best.

To all the nurses and carers, I hope your job, our job, gets properly recognized and rewarded one day. You are super humans, and the last remains of humanity and compassion in a world that 

sometimes seems to have lost its way.

• The human right to health guarantees a system of health protection for all.
• Everyone has the right to the health care they need, and to living conditions that enable us to be healthy, such as adequate food, housing, and a healthy environment.
• Health care must be provided as a public good for all, financed publicly and equitably.

This is not a goodbye, it is a see you later Nursing.

Antia Veiga Feijoo

Staff Nurse

Resources:

-Research papers can be found in Google Scholar.

-http://news.sky.com/story/nurse-went-home-and-cried-because-she-could-not-find-bed-for-99-year-old-10724912

-https://radio.rte.ie/radio1highlights/i-nurses-crying-literally-crying-last-several-days/

SEPSIS

Sepsis is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This leads to blood clots and leaky blood vessels. They cause poor blood flow, which deprives your body's organs of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, blood pressure drops and the heart weakens, leading to septic shock (multisystem failure - shock).

• Anyone can get sepsis, but the risk is higher in:

-people with weakened immune systems

-infants and children

-the elderly

-people with chronic illnesses, such as diabetes, AIDS, cancer, and kidney or liver disease

-people suffering from a severe burn or physical trauma

This response may be called systemic inflammatory response syndrome (SIRS).

Causes

The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response.

A bacterial infection anywhere in the body may set off the response that leads to sepsis. Common places where an infection might start include the:

-bloodstream

-bones (common in children)

-bowel (usually seen with peritonitis)

-kidneys (upper urinary tract infection or pyelonephritis)

-lining of the brain (meningitis)

-liver or gallbladder

-ungs (bacterial pneumonia)

-skin (cellulitis)

For patients in the hospital, common sites of infection include intravenous lines, surgical wounds, surgical drains, and sites of skin breakdown, known as bedsores or pressure ulcers.

Symptoms

In sepsis, blood pressure drops, resulting in shock. Major organs and body systems, including the 

kidneys, liver, lungs, and central nervous system stop working properly because of poor blood flow.

A change in mental status and very fast breathing may be the earliest signs of sepsis.

In general, symptoms of sepsis can include: chills, confusion or delirium, fever or low body temperature (hypothermia), light-headedness due to low blood pressure, rapid heartbeat, shaking, skin rash and warm skin. Bruising or bleeding may also occur.

Fast action is key to prevent sepsis death:

Full article at: https://medlineplus.gov/news/fullstory_160574.html

Following the recommendations of The UK Sepsis Trust we can assess our patients easily. If our patient looks sick or the New Early Warning Score has triggered we should wonder if there is an infection present even if the source is not clear yet.

If there is an infection, we should look for ANY Red Flag Criteria:

If one of the above is present, the Sepsis 6 pathway should be started immediately. If none of the above is present we should look for any Amber Flag criteria:

If there is an Amber Flag criteria present a set of routine blood samples and an urgent senior review should take place within an hour, if Acute Kidney Injury is present the Sepsis 6 pathway should be started.

Sepsis 6 pathway

When the Sepsis 6 pathway has to be started, a treatment escalation plan should be made and the CPR status of the patient should be clarified. The patient has Red Flag Sepsis and all the following actions have to be completed within one hour:

If after delivering the Sepsis Six, the patient still has:

-systolic BP < 90 mmHg

-reduced level of consiousness despite resuscitation

-respiratory rate over 25 breaths per minute

-lactate not reducing

or the patient is clearly critically ill at any time, Critical Care Outreach team should be called immediately.

Sources:
-http://sepsistrust.org/
-https://medlineplus.gov/ency/article/000666.htm
-https://medlineplus.gov/news/fullstory_160574.html
-https://www.emaze.com/@AOZTZRZO/CAMPA%C3%91A-PARA-SOBREVIVIR-A-LA-SEPSIS.pptx

NAUSEA AND VERTIGO

Nausea and vomiting (also called emesis)

Nausea is an uneasy or unsettled feeling in the stomach together with an urge to vomit. Nausea and vomiting, or throwing up, are not diseases. They can be symptoms of many different conditions. 

Many common problems may cause nausea and vomiting, including:

-food allergies

-infections of the stomach or bowels, such as the "stomach flu" or food poisoning

-leaking of stomach contents (food or liquid) upwards (also called gastro-oesophageal reflux or GORD)

-medicines or medical treatments, such as cancer chemotherapy or radiation treatment

-migraine headaches

-morning sickness during pregnancy

-seasickness or motion sickness

-severe pain, such as with kidney stones

Nausea and vomiting may also be early warning signs of more serious medical problems, such as appendicitis, blockage in the intestines, cancer or a tumor, ingesting a drug or poison (especially by children) or ulcers in the lining of the stomach or small intestine.

Nausea and vomiting are common. Usually, they are not serious. Medical advice should be sought immediately if :

-vomited for longer than 24 hours

-blood in the vomit

-severe abdominal pain

-headache and stiff neck

-signs of dehydration, such as dry mouth, infrequent urination or dark urine.

Vertigo

The most common symptoms of vertigo include a feeling of spinning (you or the room around you), tilting or swaying and feeling off balance. These feelings come and go, and may last seconds, hours, or days. You may feel worse when you move your head, change positions (stand up, roll over), cough, or sneeze. Along with vertigo, you may vomit or feel nauseous, have a headache or be sensitive to light and noise, see double, have trouble speaking or swallowing, feel weak or short of breath or sweaty and have a racing heart beat.

The most common causes of vertigo include:

• Inner ear problems: collections of calcium, inflammation, and certain infections can cause problems in the vestibular system. The vestibular system includes parts of the inner ear and nervous system, which controls balance.
• Benign paroxysmal positional vertigo (BPPV): sometimes called benign positional vertigo, positional vertigo, postural vertigo, or simply vertigo, is a type of vertigo that develops due to collections of calcium in the inner ear. These collections are called canaliths. Moving the canaliths (called canalith repositioning) is a common treatment for BPPV. Vertigo is typically brief in people with BPPV, lasting seconds to minutes. Vertigo can be triggered by moving the head in certain ways.
• Meniere disease:  is a condition that causes repeated spells of vertigo, hearing loss, and ringing in the ears. Spells can last several minutes or hours. It is probably caused by a buildup of fluid in the inner ear. 
• Vestibular neuritis: vestibular neuritis, also known as labyrinthitis, is probably caused by a virus that causes swelling around the balance nerve. People with vestibular neuritis develop sudden, severe vertigo, nausea, vomiting, and difficulty walking or standing up; these problems can last several days. 

• Head injury: head injuries can affect the vestibular system in a variety of ways, and lead to vertigo.
• Medications: rarely, medications can actually damage or affect the function of the inner ear or brain and lead to vertigo.
• Migraines: in a condition called vestibular migraine or migrainous vertigo, vertigo can be caused by a migraine. This type of vertigo usually happens along with a headache.
• Brain problems, such as a stroke or TIA (transient ischemic attack), bleeding in the brain, or multiple sclerosis can also cause vertigo. 

-Drugs used in nausea and vertigo:

• Antihistamines:                                                                         

           -cinnarizine (Stugeron, Arievert)                                                        -cyclizine (Valoid)                                                                    

           -promethazine hydrochloride                                                              -promethiazine teoclate (Avomine).                                                              

• Phenothiazines and related drugs: 

            -chlorpromazine hydrochloride

            -perphenazine

            -prochlorperazine (Stemetil, Buccastem)

            -trifluoperazine.

• Domperidone and metoclopramide:

           -domperidone (Motillium)                                      

           -metoclopramide hydrochloride (Maxolon)

• 5HT3 antagonists:

           -dolasetron mesilate (Anzemet)

           -granisetron (Kytril)

           -ondansetron (Zofran)

           -palonosetron (Aloxi)

• Neurikinin receptor antagonist:

          -aprepitant (Emend)

          -fosaprepitant (Ivemend)

• Cannabinoid: nabilone

• Hyoscine: hyoscine hydrobromide (Joy Rides, Kwells, Scopoderm TTS patches)

• Other drugs for Meniere's disease: betahistine dihydrochloride (Serc).  

Sources:

-https://medlineplus.gov/nauseaandvomiting.html

-http://www.medscape.org/

-https://medlineplus.gov/dizzinessandvertigo.html

-http://www.uptodate.com/contents/dizziness-and-vertigo-beyond-the-basics?view=print

-http://backinmotionfl.com/stop-suffering-vertigo/

-http://www.manxhealthcare.com/products/betahistine.html

-https://www.theindependentpharmacy.co.uk/onlinedoctor/treatment/cyclizine-50mg-tablets100/