Assessment skills vital to sound nursing practice: an accurate nursing assessment can save a patient's life. Here a nurse describes how one such assessment did just that. She also outlines how more than a decade later that assessment still influences her practice.

ASSESSMENT SKILLS are the first and most important ingredient in the multi-faceted mix that constitutes safe nursing care. Accurate assessment can save a patient's life. In my 22-year enrolled nursing career, predominantly in orthopaedics, I have repeatedly seen how accurate assessment, sometimes combined with intuition born out of experience, has saved lives.

I will always remember--for many different reasons--a particular patient, Chris Neyle, who, when I first nursed him, had endured several operations and complications following an horrific motorcycle accident.

At the time of the accident in 1983--on Friday, July 13--he was a 29-year-old boat builder and shipwright due to travel to America, hoping to work there on New Zealand's America's Cup challenge in San Diego, California. While riding his motorcycle, he was hit by a car driven by a drunk driver, resulting in multiple injuries, the most critical to his right femur. Five inches of bone was traumatically torn from his femur and ground into the road, with a severe amount of tissue loss in that area.

His left shoulder was dislocated, with a compound fracture of the proximal humerus, his right patella was shattered and part of his left patella as well.

When the ambulance arrived, Chris was lying on the road, blood surrounding his 6ft 2in frame. Unconscious on arrival at Middlemore Hospital's Emergency Department, he came to and overheard the surgeons discussing amputation of his right leg. He remembers yelling emphatically, "no way, you save my leg!".

The subsequent surgery took more than 16 hours, during which Chris had an "out-of-body" experience. Admitted to the intensive care unit, he was in a drug-induced coma for several days. He spent several weeks in traction, then underwent a bone graft, which involved taking substantial bone tissue from his iliac crest and inserting metal plates. This procedure was not successful.

After a long discussion with the orthopaedic team, he was informed that a new type of surgery was available--an allograft--though it had not been performed in New Zealand. Chris was keen to accept this alternative but had to wait until the head of the hospital's orthopaedic team Professor Harley Gray returned from America to "pioneer" the surgery. An allograft is the transfer of tissue between two genetically dissimilar individuals of the same species. Bone allografts are used mainly for limb-sparing surgery, when dealing with bone tumours or severe trauma cases. Bone segments for allografts are procured from deceased donors.

While awaiting the pioneering surgery, Chris was in traction and his right femur required major daily dressings for three months. After this wait, he received the first allograft ever performed in New Zealand. The procedure was performed by Gray, Garnet Tregonning and Gary French and included inserting a metal rod through the medullary canal of his femur and through the allograft segment. To repair the extensive tissue loss, this area was successfully skin grafted, with the donor site being his left thigh. He was finally discharged home five months after the accident, in a full fibreglass body cast that was removed a year later.

Several weeks after the removal of the cast, Chris noticed his right femur appeared to be "bending" when walking. Subsequent x rays indicated a loosening of the rod and signs of infection. He then had to lace further surgery, and was once again offered the option of amputation, which he declined. Instead, the allograft was re moved, the femur was rejoined and an external framework with six metal pins was inserted--a Hoffman's Fixation. He was then back to a full fibreglass body cast for another 12 months. Three months after removal of the second cast, the metal pins were removed. Chris also had to wear a five-inch, built-up shoe to compensate. This made it very difficult for him to effectively continue his boat building career. At this point he was foreman of the building of the America's Cup boat "KZI" and had a promising career ahead of him. After three years of frustration coping with the built-up shoe, in 1986 he elected to have further surgery to shorten his left femur by three inches. After the initial surgery, two further operations were required, as the intramedullary femoral rod was not adequate for stability, and two metal pins, one at each end of the femur, were inserted in two separate operations. Up to this point he had undergone a total of nine operations.

I first met Chris in 1986, a few days after the third operation on his left femur. He appeared quite positive psychologically, yet I had a "gut feeling" that something was physically wrong. His base-line recordings were stable but he appeared a little disorientated and nauseated. His skin was sweaty and clammy to touch, although he was afebrile. His left thigh, warm to the touch, seemed excessively swollen, even taking into account such extensive surgery. The five redivacs were patent and draining, with about 200mls in each. I reported my concerns to the charge nurse, stating I felt sure Chris was in the early stages of septic shock, though at that point, medical staff had not indicated any need for concern. After examining him she agreed and blood gases were taken immediately. Chris had been feeling nauseous all that duty and had not eaten, which was just as well, as he had to return to theatre urgently, where more than 500mls of pus was drained from his leg. A further two inches of bone had to be removed to get to healthy bone. The femoral rod was removed, due to the infection, and another external fixation was applied, with 12 metal pins this time.

Chris then had to endure another full body cast for another year. The odds of a successful prognosis post-operatively were only 50 percent. Chris later quipped, with Iris off-beat sense of humour, "Well, at least now I'm on even keel!"

After being commended on my assessment skills, I was informed by the orthopaedic team that if he had been left undiagnosed for a further eight to ten hours, the team would most likely have had to amputate his "good leg" as a life saving measure; another 12 to 24 hours and septicaemia may well have cost him his life.

After the removal of five inches of femur, the surrounding excessive tissue was completely reabsorbed by the body over several months.

The human body never ceases to amaze me! And Chris proved many times over the old adage that man's strongest instinct is survival. At the time of his accident Chris was extremely fit and healthy, a champion motor cross rider, with a black belt in ka rate, into speedboats and swimming. As a 12-year-old he had won a state swimming championship in New South Wales. There is no doubt in my mind his fitness and spirit were major factors in his recovery. With a great deal of courage, determination and a positive attitude, he survived the whole traumatic experience, spending several more months in Middlemore Hospital. On his final discharge in late 1986, after a total of more than a year in hospital, the nurses gave him a tee-shirt with the caption "I'm a ward 20 survivor!". He most certainly is a survivor and a fighter.

Even though he was incredibly "reduced" in height from 6ft 2in to 5ft 8in (a further one inch deficit due to bone absorption) today he walks "tall" , with only a slight limp and he has no regrets about his decision to have his left femur shortened.

In gratitude for the many units of lifesaving blood he received, he became and still is, a regular blood donor. After such long-term use of intravenous antibiotics, he has a 13 percent hearing loss and has a high risk of developing osteomyelitis, if he ever requires further surgery. His severe shoulder injury left him with a brachial plexus palsy and he had six years of intense physiotherapy to regain a functional arm. He recently had a successful left total shoulder joint replacement. At present he is waiting for surgery on his right leg to release tendons and possibly have his horrendous scar tissue removed.

Despite the numerous setbacks, both physical and psychological, 20 years on, Chris is still singing the praises of the surgeons, nurses, physiotherapists and all the health care team at Middlemore Hospital involved in his hospitalisation and rehabilitation.

This experience, although so long ago, still very much affects my nursing practice today. I always go with my "gut feelings", speak up as an advocate for my patients and am prepared to act on those feelings, regardless of whether others disagree or further intervention is not clinically indicated. This attitude enables me to practise as a more effective nurse and to gain a huge increase in job satisfaction as well.

As well as the sheer severity of Chris's injuries, the length of his treatment, and my critical intervention which picked up he was in the early stages of septic shock, another reason Chris is special to me, is that he is now my husband.

Six years after his final discharge from Middlemore Hospital, our paths crossed again. We met by chance at an Auckland market and began a friendship, which developed into a relationship. In September i999, on a beautiful sun-drenched day, Chris and I were married at the Grand Canyon in the United States in a traditional Native American wedding ceremony. As "Amazing Grace", sung in Cherokee, echoed across the canyon, we stood on the ancient "worship site", an intricately placed pile of rocks, sacred to the Native American. A Native American wedding blessing was read at the closing of our ceremony. It read: "Now you will feel no rain for each of you will be a shelter to the other. Now you will feel no cold for each of you will be warmth to the other. Now there is no loneliness for you. Now you are two bodies but there is one life before you. Go now to enter into the days of your togetherness and may your days be good and long upon the earth."

With the back drop of awesome beauty and caught up in the emotion of the moment, I glanced at my new husband. He stood on his rocky precipice looking down on the towering pastel-coloured rocks and I thought, from this angle somehow he appears over ten feet tall!

The Grand Canyon is undoubtedly a natural wonder of the world, and in my heart, I believe, so is my husband.

--June Neyle, EN, has worked in orthopaedic wards at Middlemor e Hospital for the last 21 years.