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OXFORD MEDICAL HANDBOOKS

Oxford Handbook of
Critical Care
Nursing
Published and forthcoming Oxford Handbooks in Nursing
Oxford Handbook of Adult Oxford Handbook of Mental
Nursing Health Nursing, 2e
George Castledine and Ann Close Edited by Patrick Callaghan and
Oxford Handbook of Cancer Catherine Gamble
Nursing Oxford Handbook of Midwifery,
Edited by Mike Tadman and Dave 2e
Roberts Janet Medforth, Susan Battersby, Maggie
Oxford Handbook of Cardiac Evans, Beverley Marsh, and Angela
Nursing, 2e Walker
Edited by Kate Olson Oxford Handbook of
Oxford Handbook of Children’s Musculoskeletal Nursing
and Young People’s Nursing, 2e Edited by Susan Oliver
Edited by Edward Alan Glasper, Gillian Oxford Handbook of
McEwing, and Jim Richardson Neuroscience Nursing
Oxford Handbook of Clinical Edited by Sue Woodward and
Skills for Children’s and Young Catheryne Waterhouse
People’s Nursing Oxford Handbook of Nursing
Paula Dawson, Louise Cook, Laura-Jane Older People
Holliday, and Helen Reddy Beverley Tabernacle, Marie Barnes, and
Oxford Handbook of Clinical Skills Annette Jinks
in Adult Nursing Oxford Handbook of Orthopaedic
Jacqueline Randle, Frank Coffey, and and Trauma Nursing
Martyn Bradbury Rebecca Jester, Julie Santy, and Jean
Oxford Handbook of Critical Care Rogers
Nursing Oxford Handbook of
Sheila Adam and Sue Osborne Perioperative Practice
Oxford Handbook of Dental Suzanne Hughes and Andy Mardell
Nursing Oxford Handbook of Prescribing
Kevin Seymour, Dayananda for Nurses and Allied Health
Samarawickrama, Elizabeth Boon, Professionals
and Rebecca Parr Sue Beckwith and Penny Franklin
Oxford Handbook of Diabetes Oxford Handbook of Primary
Nursing Care and Community Nursing
Lorraine Avery and Sue Beckwith 2e
Oxford Handbook of Emergency Edited by Vari Drennan and Claire
Nursing Goodman
Edited by Robert Crouch, Alan Oxford Handbook of Renal
Charters, Mary Dawood, and Paula Nursing
Bennett Edited by Althea Mahon, Karen Jenkins,
Oxford Handbook of and Lisa Burnapp
Gastrointestinal Nursing Oxford Handbook of Respiratory
Edited by Christine Norton, Julia Nursing
Williams, Claire Taylor, Annmarie Terry Robinson and Jane Scullion
Nunwa, and Kathy Whayman Oxford Handbook of Women’s
Oxford Handbook of Learning and Health Nursing
Intellectual Disability Nursing Edited by Sunanda Gupta, Debra
Edited by Bob Gates and Owen Barr Holloway, and Ali Kubba
Oxford Handbook of
Critical Care
Nursing
Second Edition

Heather Baid
Fiona Creed
Jessica Hargreaves

1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
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The moral rights of the authors have been asserted
First Edition published in 2009
Second Edition published in 2016
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Published in the United States of America by Oxford University Press
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Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
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and the most recent codes of conduct and safety regulations. The authors and
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Links to third party websites are provided by Oxford in good faith and
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contained in any third party website referenced in this work.
 v

Preface

Since the publication of the first edition of the Oxford Handbook of Critical
Care Nursing there have been a number of significant changes in the man-
agement of the critically ill adult that have necessitated a review of that
edition.
Therefore the second edition has been updated to reflect changes in crit-
ical care guidance for the management of a variety of conditions. Current
guidance from organizations such as the National Institute for Health and
Care Excellence, the British Association of Critical Care Nurses, and the
Intensive Care Society has been included.
In addition to the updating of clinical guidance, the book has been restruc-
tured following extensive feedback on the previous edition. An emphasis
has now been placed on nursing management, and the book is designed
to help to facilitate systematic nursing assessment of the critically ill adult.
New chapters focusing on changes in the delivery of critical care, systematic
assessment, and end-of-life care have also been added.
It is hoped that readers will find the new structure easy to follow and
helpful in clinical practice. The handbook aims to provide a quick, easy-to-
follow overview of critical care nursing, and is not intended as a specialist
text. Readers may need to refer to specialist critical care resources if further
information is required.
It is our hope that the book will prove valuable to you in your everyday
practice as a critical care nurse.
Heather Baid
Fiona Creed
Jessica Hargreaves
vi

Acknowledgements

Firstly and foremost we would like to express our thanks to Sheila Adam
and Sue Osborne for allowing us to build upon their original work.
We would also like to thank the following individuals and organizations
who have contributed in various ways to the second edition of this book:
• Our work colleagues Thelma Lackey and Erika Thorne for providing
expert advice and review.
• The book reviewers who all provided constructive and helpful feedback
throughout the production process.
• The British Association of Critical Care Nurses (BACCN) for allowing
reproduction of their material within the book.
• The National Institute for Health and Care Excellence (NICE) for
allowing reproduction of their material within the book.
• The Resuscitation Council (UK) for granting permission to use their
resuscitation algorithms.
• The editing team at Oxford University Press for all their support
throughout the production process.
 vii

Contents

Symbols and abbreviations viii

1 Admission to critical care    1

2 Systematic assessment 15
3 Generic care of the critically ill patient 41
4 Respiratory assessment and monitoring 101
5 Respiratory support 133
6 Cardiovascular assessment and monitoring 167
7 Cardiovascular support 209
8 Neurological care 241
9 Renal care 277
10 Gastrointestinal care 295
11 Sepsis 327
12 Metabolic disorders 343
13 Immunology 367
14 Haematology 383
15 Managing emergencies 405
16 Obstetric emergencies 423
17 Poisoning 439
18 Trauma 459
19 End-of-life care 497
20 Transfer of the critical care patient 515
21 Rehabilitation and discharge 523

Index 533
viii

Symbols and abbreviations

d decreased
i increased
E cross-reference
M website
ABG arterial blood gas
ACE angiotensin-converting enzyme
ACS acute coronary syndrome
ACT activated clotting time
ADH antidiuretic hormone
AFB acid-fast bacilli
AFE amniotic fluid embolism
AKI acute kidney injury
ALL acute lymphatic leukaemia
ALS advanced life support
ALT alanine aminotransferase
AML acute myeloid leukaemia
APACHE II Acute Physiology and Chronic Health Evaluation II
APC antigen-presenting cell
APRV airway pressure release ventilation
APTT activated partial thromboplastin time
ARDS acute respiratory distress syndrome
AST aspartate aminotransferase
ATLS advanced trauma life support
AV atrioventricular
AVPU Alert Verbal Pain Unresponsive
BACCN British Association of Critical Care Nurses
BIS Bispectral Index
BMI body mass index
BPAP bi-level positive airway pressure
BPS Behavioural Pain Scale
BSD brainstem death
CAM-ICU Confusion Assessment Method-ICU
 SYMBOLS AND ABBREVIATIONS ix

CLL chronic lymphatic leukaemia

CML chronic myeloid leukaemia
CMV controlled manual ventilation; cytomegalovirus
CNS central nervous system
COPD chronic obstructive pulmonary disease
CPAP continuous positive airway pressure
CPP cerebral perfusion pressure
CRP C-reactive protein
CSF cerebrospinal fluid
CSW cerebral salt wasting
CT computerized tomography
CVP central venous pressure
CVS cardiovascular system
CVVH continuous venovenous haemofiltration
CVVHD continuous venovenous haemodialysis
CVVHDF continuous venovenous haemodiafiltration
DI diabetes insipidus
DIC disseminated intravascular coagulation
DIS daily interruption of sedation
DKA diabetic ketoacidosis
DVT deep vein thrombosis
ECG electrocardiogram
ECMO extracorporeal membrane oxygenation
EEG electroencephalogram
ERCP endoscopic retrograde cholangiopancreatography
ETCO2 end-tidal carbon dioxide
ETT endotracheal tube
EVD external ventricular drain
EVLW extravascular lung water
FBC full blood count
FFP fresh frozen plasma
FiO2 fractionated inspired oxygen concentration
FRC functional residual capacity
FTc corrected flow time
GBS Guillain–Barré syndrome
x SYMBOLS AND ABBREVIATIONS

GCS Glasgow Coma Scale

GEDV global end-diastolic volume
GFR glomerular filtration rate
GMC General Medical Council
GRV gastric residual volume
GTN glyceryl trinitrate
h hour
HADS Hospital Anxiety and Depression Scale
Hb haemoglobin
HELLP haemolysis, elevated liver enzymes and low platelets
HEPA high-efficiency particulate air
HES hydroxyethyl starch
HHS hyperglycaemic hyperosmolar state
HIT heparin-induced thrombocytopenia
HIV human immunodeficiency virus
HUS haemolytic uraemic syndrome
ICDSC Intensive Care Delirium Screening Checklist
ICP intracranial pressure
ICS Intensive Care Society
ICU intensive care unit
IHD intermittent haemodialysis
INR international normalized ratio
IPPV intermittent positive pressure ventilation
ITBV intra-thoracic blood volume
ITP idiopathic thrombocytopenic purpura
IV intravenous
IVIG intravenous immunoglobulin
JVP jugular venous pressure
L litre
LBBB left bundle branch block
LFT liver function test
LiDCO lithium dilution cardiac output
LMWH low-molecular-weight heparin
LOC level of consciousness
LVF left ventricular failure
 SYMBOLS AND ABBREVIATIONS xi

MAP mean arterial pressure

MC&S microscopy, culture, and sensitivity
MI myocardial infarction
min minute
MODS Multiple Organ Dysfunction Score; multi-organ
dysfunction syndrome
MRI magnetic resonance imaging
MV minute volume
NEWS National Early Warning Score
NICE National Institute for Health and Care Excellence
NIV non-invasive ventilation
NMBA neuromuscular blocking agent
NSAID non-steroidal anti-inflammatory drug
NSTEMI non-ST-segment elevation myocardial infarction
PA pulmonary artery
PaCO2 partial pressure of arterial carbon dioxide
PaO2 partial pressure of arterial oxygen
PAO2 partial pressure of alveolar oxygen
PAOP pulmonary artery occlusion pressure
PAP pulmonary artery pressure
PAWP pulmonary artery wedge pressure
PCA patient-controlled analgesia
PCC prothrombin complex concentrate
PCI percutaneous coronary intervention
PCV packed cell volume
PE pulmonary embolism
PEA pulseless electrical activity
PEEP positive end expiratory pressure
PEFR peak expiratory flow rate
PEJ percutaneous jejunostomy
PET positron emission tomography
PiCCO pulse contour cardiac output
POCT point-of-care testing
P-PCI primary percutaneous coronary intervention
PPH postpartum haemorrhage
xii SYMBOLS AND ABBREVIATIONS

PSV pressure support ventilation

PT prothrombin time
PVC polyvinyl chloride
PvCO2 partial pressure of venous carbon dioxide
PvO2 partial pressure of venous oxygen
PVR pulmonary vascular resistance
RASS Richmond Agitation Sedation Scale
RCN Royal College of Nursing
REM rapid eye movement
ROM range of movement
RQ respiratory quotient
RRT renal replacement therapy
RSBI Rapid Shallow Breathing Index
RVF right ventricular failure
s second
SAPS II/III Simplified Acute Physiology Score II/III
SBAR Situation, Background, Assessment, Recommendation
SBT spontaneous breathing trial
SCUF slow continuous ultrafiltration
SIADH syndrome of inappropriate secretion of antidiuretic
hormone
SIMV synchronized intermittent mandatory ventilation
SIRS systemic inflammatory response syndrome
SLE systemic lupus erythematosus
SOFA Sequential Organ Failure Assessment
SpO2 oxygen saturation in arterial blood
STEMI ST-segment elevation myocardial infarction
SVR systemic vascular resistance
SVT supraventricular tachycardia
SVV stroke volume variation
SWS slow-wave sleep
TB tuberculosis
TENS transcutaneous electrical nerve stimulation
TIA transient ischaemic attack
TMA thrombotic microangiopathy
 SYMBOLS AND ABBREVIATIONS xiii

tPA tissue plasminogen activator

TPN total parenteral nutrition
TTP thrombotic thrombocytopenic purpura
U&E urea and electrolytes
VAP ventilator-associated pneumonia
VC vital capacity
VF ventricular fibrillation
VO2 oxygen consumption
V/Q ventilation/perfusion
VT tidal volume
VT ventricular tachycardia
VTE venous thromboembolism
WBC white blood cell
WBPTT whole blood partial thromboplastin time
WFNS World Federation of Neurosurgeons Scale
 Chapter 1 1

Admission to critical care

Changes to the delivery of critical care 2

Preventing admissions to critical care 4
Levels of care 8
Admission criteria 10
Organizing admission into critical care 12
2 Chapter 1 Admission to critical care

Changes to the delivery of critical care

The changing face of acute nursing
The face of acute care and critical care has changed substantially over the
last two decades. This change has been influenced by a number of fac-
tors, but perhaps most significantly by the increasing number of acutely ill
patients within the hospital environment. A number of factors have influ-
enced patient acuity, including:
• an ageing population with increased levels of comorbidity
• use of advanced treatment modalities and technologies
• increased complexity of patient needs.
The changes in acuity levels have meant that healthcare providers have been
faced with challenges related to caring for an increasing number of acutely
and critically ill patients.
Over 15 years ago the National Audit Office1 identified a lack of provision
of critical care beds, and reported that demand for critical care beds often
exceeded the number of such beds available. This necessitated an urgent
review of critical care provision.
The publication of Comprehensive Critical Care: a review of adult critical
care services by the Department of Health2 a year later helped to redevelop
the provision of acute and critical care services in the UK. This document
marked the end of traditional boundaries associated with critical care, and
emphasized the need for a hospital-wide approach to caring for acutely and
critically ill patients.
The vision of comprehensive critical care was that hospitals should meet
the needs of all critically ill patients, not just those in designated critical
care beds, and gave rise to the concept of ‘critical care without walls.’ It
highlighted both the need to radically change critical care provision, and
the need for the following characteristics of a modern critical care service:
• integration of services beyond the boundaries of critical care units
to allow provision of acute and critical care and the optimization of
resources
• the development of critical care networks to share standards and
protocols and to develop future care provision
• workforce development to ensure that all staff caring for acutely and
critically ill patients have sufficient knowledge and training.
Recognition of deterioration
Alongside the redevelopment of critical care services, problems with
the recognition of deterioration in the patient’s condition were being
highlighted.
A seminal study by McQuillan and colleagues3 first introduced the now
well-recognized concept of suboptimal care for acutely ill adults. Suboptimal
care relates to multifactorial issues that contribute to misdiagnosis, misman-
agement, and lack of timely intervention for acutely ill deteriorating patients.
Delays in treating acutely ill patients were linked to unexpected deaths and
unplanned and perhaps preventable admissions to critical care units.
 Changes to the delivery of critical care 3

McQuillan and colleagues’3 study identified that over 50% of patients

encountered suboptimal management prior to admission to critical care
units. Unfortunately, similar statistics are still evident despite ongoing inter-
ventions to improve the situation. The current literature often uses the
term ‘failure to rescue’ to refer to suboptimal care.
Factors related to suboptimal care—or, more recently, ‘failure to
rescue’—include:
• lack of knowledge and lack of experience in dealing with acutely ill
patients
• failure to appreciate the urgency of the need to treat the patient’s
condition
• failure to seek senior or expert advice about the patient’s condition
• lack of senior medical staff involvement
• organizational failings that prevent adequate assessment and
management of the deteriorating patient.
A number of initiatives have been developed to improve recognition and
management of the deteriorating patient. Analysis of the literature suggests
that the number of preventable deaths and unplanned critical care admis-
sions could be reduced if deteriorating patients were identified earlier and
managed in a timely manner.

References
1 National Audit Office. Critical to Success: the place of efficient and effective critical care services within
the acute hospital. Audit Commission: London, 1999.
2 Department of Health. Comprehensive Critical Care: a review of adult critical care services.
Department of Health: London, 2000.
3 McQuillan P et al. Confidential inquiry into quality of care before admission to intensive care.
British Medical Journal 1998; 316: 1853–8.
4 Chapter 1 Admission to critical care

Preventing admissions to critical care

A number of initiatives have been implemented to help to prevent the
admission of acutely ill patients into critical care units. These initiatives
include:
• development of critical care outreach teams
• development of early warning scores
• utilization of medical emergency teams
• education initiatives.
Critical care outreach
The widespread development of critical care outreach services followed
the publication of Comprehensive Critical Care: a review of adult critical care
services.4 Indeed, the National Institute for Health and Care Excellence
(NICE)5 identified the need to establish outreach services in all acute hospi-
tals 24 hours a day, 7 days a week.
Outreach teams were initially established with the following key aims:
• to avert admission to critical care units
• to support staff in ward areas
• to provide education programmes for ward-based staff
• to support critical care patients following transfer from critical care, in
order to avert readmissions
• to provide follow-up services on discharge from hospital, to determine
the impact of critical care on the patient.
The implementation of outreach has not been consistent across acute
trusts, and various teams have been developed. These include:
• critical care outreach teams
• patient at-risk teams
• rapid response teams.
Although differences exist between various configurations of critical care
outreach teams, these teams are generally nurse led and have been intro-
duced to support and help to educate ward nurses when they are caring for
deteriorating and acutely ill patients. Unfortunately there is little substan-
tive research to support the effectiveness of outreach in improving patient
outcomes. Therefore more research is needed to review the effectiveness
of the role of outreach.6
Early warning scores
These were introduced to try to help ward staff to recognize and respond
to deteriorating patients on general wards. The systems use routine physi-
ological measurements, and each measurement is given a numerical value
depending on the variation from normal parameters. The individual param-
eter scores are added together and an aggregate score is then obtained that
highlights the need for patient review. Put simply, the higher the score, the
more ill the patient is. The early warning scores are linked to an escalation
process.
 Preventing admissions to critical care 5

Table 1.1 NEWS abnormal observation values

3 2 1 1 2 3
Respiratory rate ≤ 8 9–11 21–24 ≥ 25
(breaths/min)
Heart rate ≤ 40 41–50 91–110 111–130 ≥ 131
(beats/min)
Systolic blood ≤ 90 91–100 100–110 ≥220
pressure
(mmHg)
Temperature ≤ 35 35.1–36 38.1–39 ≥ 39.1
(°C)
Oxygen ≤ 91 92–93 94–95
saturation (%)
Supplemental Yes
oxygen
Level of V, P, or U
consciousness

Table 1.2 NEWS escalation tool

NEWS score Frequency of monitoring Clinical response
0 Minimum of 12-hourly Continue routine NEWS
monitoring
Total: Minimum of 4- to 6-hourly Inform registered nurse
1–4
Total: Hourly observations Inform medical team urgently
5 or more Urgent assessment by clinician
or with core competencies
3 in one Monitoring required
parameter
Total: Continuous observations Immediately inform specialist
7 registrar
or more Emergency assessment by staff
with critical care competencies
Consider move to higher level
of care
Another random document with
no related content on Scribd:
 ANNALS
OF

THE EARLY CALIPHATE.

 CHAPTER I.
ELECTION OF ABU BEKR.

A.H. XI. A.D. 632.

At eventide of a summer day in the

eleventh year of the Hegira, three chief Death of Mahomet, 13 Rabi
I. a.h. XI., June 8, a.d. 632.
‘Companions’ of Mahomet might be seen
issuing in haste from the Great Mosque at Medîna, where, close by
in the chamber of Ayesha, his favourite wife, the Prophet of Arabia
lay dead.[4] They were Abu Bekr, Omar, and Abu Obeida. I will first
describe each briefly, and then explain the object of their errand.
Abu Bekr, now threescore years of
age, was somewhat short in stature, of a Abu Bekr.
spare frame, rounded back, and stooping
gait. His face was thin, complexion smooth and fair, nose aquiline
and sharp, with other features delicate; the forehead high; the eyes
deep-seated and far apart; the veins well marked. His scanty hair
and beard, now for many years white, was dyed red. The
countenance was still in old age handsome; and the expression mild,
but wise and resolute. To him faith in the Prophet had become a
second nature, and, now that his Master was gone, the disciple lived
but to fulfil his will. It was this that nerved a disposition naturally soft
and yielding, and made Abu Bekr, the True,[5] of all the followers of
Mahomet, the firmest and most resolute.
Omar, fifteen years younger, differed
both in frame and temperament. Broad- Omar.
shouldered and tall, he towered above the
crowd. Though somewhat dark in complexion, the face was fresh
and ruddy. He was now bald; and his beard was dyed like his
friend’s. His stride was long, and his presence commanding.
Naturally hasty and passionate, he would twist his moustache when
angry and draw it downwards to his mouth. But time had mellowed
temper; and, beneath an imperious manner, he was bland and
courteous. Their attachment to Mahomet had, on these two friends,
an effect exactly opposite. That which braced the soft nature of Abu
Bekr served to abate the vehemence of Omar. Both stood in a like
relation to the Prophet, each having given a daughter to him in
marriage; Haphsa, Omar’s daughter, was one of Mahomet’s
favourite wives; but Ayesha, the child of Abu Bekr, was queen in his
affections to the end.
On these two men at this moment hung
the future of Islam. The third, who now Abu Obeida.
accompanied them, Abu Obeida, was
between them in age. He was thin, tall, and sinewy; bald, and with
little beard. Mild, unassuming, and unwarlike, he was yet destined to
take a leading part in the conquest of Syria.

It was the afternoon of the day on

which, but an hour or two before, Mahomet Abu Bekr and Omar in the
had breathed his last. The event had come Great Mosque.
unexpectedly at the end. Abu Bekr, thinking the Prophet better, had
shortly before retired to his house in the suburbs of the city. Called
back in haste, he entered Ayesha’s chamber, and kissed the face of
his departed friend, saying:—
‘Sweet wert thou in life; and sweet thou
art in death.’ The mosque was filled with a Men of Medîna would elect a
crowd excited by the voice of Omar, who chief of their own.
wildly proclaimed that the Prophet was not dead, but in a trance; and
that, like Moses, he would surely return to them again. Abu Bekr,
issuing from the chamber (which opened directly from the court of
the mosque), put his friend aside with these memorable words:—
Whoso worshippeth Mahomet, let him know that Mahomet is dead
indeed; but whoso worshippeth God, let him know that God liveth
and dieth not. He added passages from the Corân, in which the
Prophet had said that he would die; and Omar, hearing them as if he
had never heard them before, was speechless. The multitude
quieted down before the solemn words of Abu Bekr. But just then a
messenger hurried up with the report, that the citizens of Medîna—
the Ansâr, had assembled to choose for themselves a chief. The
moment was critical. The unity of the faith was at stake. A divided
power would fall to pieces, and all might be lost. The mantle of the
Prophet must fall upon one successor, and on one alone. The
sovereignty of Islam demanded an undivided Caliphate; and Arabia
would acknowledge no master but from amongst the Coreish. The
die must be cast, and at once.
Such, no doubt, were the thoughts
which occurred to Omar and Abu Bekr on Stormy scene in the hall of
receiving intelligence of the elective the citizens.
conclave; and so, alarmed at the danger, they hastened to the spot,
accompanied by Abu Obeida, if haply they might nip it in the bud. On
the way they met two friendly citizens coming from the assembly,
who warned them of the risk they ran; but, notwithstanding, they
hurried on. The men of Medîna meanwhile, gathered in one of their
rude halls, were bent upon an independent course. ‘We have
sheltered this nest of strangers,’ they cried. ‘It is by our good swords
they have been able to plant the Faith. The Chief of Medîna shall be
from amongst ourselves.’ And they had already fixed their choice on
Sád ibn Obâda, leader of the Beni Khazraj, one of ‘the Twelve’ at
‘the Pledge of Acaba,’ who, sick of a fever, lay covered up at the
further end of the hall. At this moment the three Companions entered
but just in time, for had the Citizens elected Sád and pledged their
troth to him, Medîna might have been irretrievably compromised.
Omar, with his native vehemence, was about to speak, when Abu
Bekr bade him to be silent, and anticipated him, as Omar used in
after days to say, with the same arguments he himself had thought
of, and even better. ‘Every word,’ said Abu Bekr, calmly and firmly,
‘which the Citizens had uttered in their own praise was true, but in
noble birth and influence the Coreish were paramount, and to none
but them would Arabia yield obedience.’ ‘Then,’ cried the men of
Medîna, ‘let there be one chief from amongst you and one from
amongst us.’ ‘Away with you!’ exclaimed Omar; ‘two cannot stand
together’; and even Sád from beneath his covering muttered that to
divide the power would weaken it. High words ensued. Hobâb, on
the side of Sád, cried out, ‘Hear him not! Attend to me, for I am the
well-rubbed Palm-stem.[6] If they refuse, expel them from the city. I
am the Roaring Lion of the desert, and will devour them up.’ ‘The
Lord destroy thee!’ cried Omar; and Hobâb returned the words. The
altercation gaining in heat and bitterness, Abu Bekr saw that it must
be stopped at any risk; so stepping forward he said: ‘Ye see these
two’—and he pointed to Omar and Abu Obeida—‘Choose ye now
whichever of them ye will, and salute him as your Chief.’ ‘Nay,’ cried
both at once, ‘Thou hast already, at the Prophet’s bidding, led the
prayers; thou art our Chief. Stretch forth thine hand.’ He did so, and
they struck their hand on his in token of allegiance.[7] Others began
to follow their example. ‘Wilt thou cut thine own kinsman’s throat?’
cried Hobâb to a Khazrajite about to take the pledge. ‘Not so,’ he
answered; ‘I only yield the right to whom the right is due.’ Whilst they
yet hesitated, the Beni Aus, jealous of the rival tribe and of Sád its
nominee, spake among themselves: ‘If this man be chosen, the rule
will be for ever with the Beni Khazraj. Let us salute Abu Bekr as our
Chief.’[8] The example once set, group
after group advanced to place their hand Abu Bekr elected Caliph.
on that of Abu Bekr, till none was left but Sád, who still lay covered in
the corner. Acknowledged thus by the men of Medîna, there could be
no doubt of Abu Bekr’s acceptance by the Coreish and all the
Refugees.[9] He was one of themselves, and the Prophet, by
appointing him to take his place, when laid aside, at the daily
prayers, had in a manner indicated him as his vicegerent. And so
homage was done on all sides to Abu Bekr. He was saluted as the
‘Caliph,’ or ‘Successor of the Prophet.’
The night was occupied in preparing
the dead for sepulture. The body was Burial of the Prophet.
washed and laid out, and the grave dug in
Ayesha’s apartment, where Mahomet had breathed his last. On the
morrow the citizens, men, women, and children, thronged the
chamber to look once more upon their Prophet’s face. And then the
body was reverently committed to the dust.
 The funeral being over, and the court of
the Great Mosque still crowded with the Abu Bekr’s inaugural
mourners, Abu Bekr ascended the pulpit, address.
and, sitting down, was saluted as Caliph by acclamation. Then he
arose, and said: ‘O people! Now I am Chief over you, albeit not the
best amongst you. If I do well, support me; if ill, then set me right.
Follow the true, wherein is faithfulness; eschew the false, wherein is
treachery. The weaker amongst you shall be as the stronger with
me, until that I shall have redressed his wrong; and the stronger shall
be as the weaker, until, if the Lord will, I shall have taken from him
that which he hath wrested. Leave not off to fight in the ways of the
Lord; whosoever leaveth off, him verily shall the Lord abase. Obey
me wherein I obey the Lord and his Prophet; when I disobey, then
obey me not. Now, arise to prayer, and the Lord be with you!’ The
assembly stood up for prayer, and Abu Bekr, for the first time as
Caliph, filled the place of Mahomet.
Besides Sád, there were few, if any,
who refused to do homage to Abu Bekr. Sád declines to swear fealty;
According to most authorities, Aly declined and also (probably) Aly for a
time.
to do so until the death of Fâtima his wife,
six months afterwards. Zobeir and Talha are also mentioned, but
doubtfully.[10] Sád persisted in his refusal; he even threatened to
empty his quiver against the usurpers, and then fight against them
with his retainers. ‘Let him alone,’ was the advice of those around
the Caliph; ‘he is but a single man, and his secession will not signify;
but if force be used against him, then his tribe will fight.’ The advice
approved itself to Abu Bekr’s forbearing spirit. Sád kept aloof, and
never appeared at court or in the mosque. When Omar succeeded to
the Caliphate, he presented himself with these words, ‘I love thee
not, O Omar!’ and, disappearing, eventually died in Syria.
With Mahomet ceased the theocratic
power which, as a prophet, he had The succession, how far
provided for by Mahomet;
exercised; but the kingly functions, as ruler and the precedent now
over all Islam, descended to his successor. established.
According to Arabian notions, such a ruler
was, like the Chieftain of a tribe, the head and representative of the
people, and his nomination was incomplete till confirmed by their
homage. Omar, we are told, in after days declared that the irregular
election of Abu Bekr (referring apparently to the scene enacted in the
hall) should not be drawn into a precedent. It was, he said, an event
the happiest in its consequences for Islam, but justified only by the
urgency of the moment. What might have been the issue if any son
of Mahomet had survived, it is useless to speculate. But certainly the
hereditary descent of kingly power was foreign to the sentiment of
Arabia. As matters stood, Mahomet seems to have shrunk from
anticipating the contingency of his death, and made no preparation
for what should follow. But in so far as we may suppose him to have
felt his illness mortal and his death impending, the nomination of Abu
Bekr to conduct the public prayers (the acknowledged mark of chief
or delegated authority) may be held the natural indication of his wish
that he should succeed.[11] Apart from the counter-claim of the men
of Medîna, there was, in point of fact, neither doubt nor hesitancy in
the election, and the counter-claim died away almost as soon as
made. The notion of divine right, or even of preferential claim, resting
in the Prophet’s family, was the growth of a later age.
 CHAPTER II.
EXPEDITION OF OSÂMA TO THE SYRIAN BORDER.

A.H. XI. A.D. 632.

Abu Bekr soon had the opportunity of

showing that he was resolved to carry out Osâma ordered by Mahomet
the commands of Mahomet to the very to lead an expedition against
the Syrian border, a.h. XI.
letter. A few weeks previously an May, a.d. 632.
expedition had been ordered to avenge by
a raid on the Syrian border the disaster which, three years before,
had tarnished the Moslem arms. In that reverse Zeid, the Prophet’s
bosom friend, who led the army, was with many others slain at Mûta;
and the more distinctly now to mark the object of the campaign, his
son Osâma, though still a youth, was nominated by Mahomet to the
command, and bidden to avenge his father’s death. The camp was
formed at Jorf, a little way on the Syrian road; but during the
Prophet’s sickness the force remained inactive, uncertain of the
issue. When the fatal event took place, Osâma broke up the camp,
and carrying back the banner which he had received at the hands of
Mahomet, planted it in the court of the Great Mosque, close by the
door of Ayesha’s apartment.
The day following his inauguration as
Caliph, Abu Bekr took up the banner, and Abu Bekr deaf to
reclamations against its
placing it in the hands of Osâma, in token dispatch.
that he was still commander, bade the
army again assemble and encamp, as it had done before, at Jorf;
and not a man was to be left behind. Obeying the command, the
fighting men of Medîna and its neighbourhood flocked again to the
camp, and even Omar was amongst the number. While yet preparing
to depart, the horizon darkened suddenly. Report of the Prophet’s
mortal illness, followed by tidings of his death, had spread like
wildfire over the land. From every side there now came rumours of
disloyalty, and of the resolve to cast the yoke of Islam off. The sense
of the army, and of Osâma himself, was strongly against leaving the
city thus defenceless, and the Caliph exposed to the risk of sudden
inroad. Omar was deputed to represent this to Abu Bekr, and also to
urge (as had been already urged to Mahomet himself[12]) that, if the
expedition must proceed, some more experienced general should
command. To the first request Abu Bekr replied, calm and unmoved:
‘Were the city swarming round with packs of ravening wolves, and I
left solitary and alone, the force should go; not a word from my
Master’s lips shall fall to the ground.’ At the second demand the
Caliph’s anger kindled: ‘Thy mother be childless, O son of Khattâb!’
he said, seizing Omar by the beard. ‘Shall the Prophet of the Lord
appoint a man to the command, and I, deposing him, appoint
another in his place?’ So Omar returned, without gaining either
object, to the army.
When all was ready for the march, Abu
Bekr repaired to the camp, and He accompanies it a little
way on foot. June, a.d. 682.
accompanied the force a little way on foot,
‘Be mounted,’ said Osâma to him; ‘or else I will dismount and walk
by thee.’ ‘Not so,’ replied Abu Bekr; ‘I will not mount; I will walk and
soil my feet, a little moment, in the ways of the Lord. Verily, every
step in the ways of the Lord is equal to the merit of manifold good
works, and wipeth out a multitude of sins.’ After a while he stopped,
and said to Osâma: ‘If it be thy will, give Omar leave that he may
return with me to the city, for strength and counsel.’ So he gave him
leave.[13]
The army then halted, to receive the
parting injunctions of the Caliph. ‘See,’ said And gives Osâma
he, addressing Osâma, ‘that thou avoid instructions.
treachery and deceit. Depart not in any wise from the right. Thou
shalt mutilate none; neither shalt thou kill child or aged man, nor any
woman. Injure not the date-palm, neither burn it with fire; and cut not
down any tree wherein is food for man or beast. Slay not of the
flocks or herds or camels, saving for needful sustenance. Ye may eat
of the meat which the men of the land shall bring unto you in their
vessels, making mention thereon of the name of the Lord. And the
monks with shaven heads that spend their lives in monasteries, if
they submit, leave them in their cloisters unmolested. Now march
forward in the name of the Lord, and may He protect you from sword
and pestilence!’
So Abu Bekr returned with Omar to
Medîna. Osâma marched by Wâdi al Cora, Osâma returns victorious,
July and August.
in the direction of Dûma, Obna, and the
highlands south of Syria. The brunt of his attack fell upon the Beni
Codhâa, and the semi-Christian tribes which, under the Roman
banner, had discomfited and slain his father. That disaster was now
avenged in fire and blood. The land was ravaged far and near, and
after an absence of two months, the army returned laden with spoil.
[14]

Meanwhile stirring events had transpired at Medîna, of which an

account is given in the chapter following.
 CHAPTER III.
MEDINA THREATENED.

A.H. XI. June and July, A.H. 632.

In after days Abu Bekr used to look

back with a just pride and satisfaction to Beneficial effects of Osâma’s
his despatch, against a universal expedition.
reclamation, of Osâma’s force. Public opinion was not long in
justifying the act and attributing thereto results of essential benefit.
The firmness of his attitude inspired the Bedouin tribes with a sense
of stability in the government. If the leaders at Medîna had not been
confident in their strength at home they would not have sent away
this army; and the Arabs, reasoning thus, were restrained from much
that they might otherwise have attempted. Still the position was
critical, and at times sufficiently alarming.
It was indeed a thing of which the brave
old Caliph might proud. ‘The Arabs,’ so the Courageous attitude of Abu
tradition runs, ‘were on all sides rising in Bekr.
rebellion. Apostasy and disaffection began to raise their heads;
Christians and Jews to stretch out their necks; and the Faithful were
left like a flock of sheep without a shepherd—their Prophet gone,
their numbers few, and their foes a multitude.’ It was in face of all this
that Abu Bekr sent off beyond recall his only force, and left Medîna
open and, to the outward eye, defenceless.
During the lifetime of Mahomet three
rivals had already laid claim to the Insurrection throughout
Arabia.
prophetic office and raised the standard of
rebellion. In the south, insurrection had hardly been quelled by the
assassination of the ‘Veiled Prophet’ of Yemen, when tidings of the
death of Mahomet made it burst forth with redoubled violence.
Enshrined in the very centre of the peninsula, Moseilama had
detached the powerful tribes around Yemâma from their allegiance;
and to the north-east, nearer home, Toleiha, the third pretender, was
now openly and dangerously hostile.[15] From every quarter, in rapid
succession, came the news of spreading disaffection. The legates of
Mahomet, the collectors of tithes—all, in fact, who represented the
authority of Islam—fled or were expelled. The Faithful were
massacred, and some confessors suffered a cruel death. Mecca and
Tâyif quivered and vacillated at the first intelligence of the Prophet’s
decease; in the end, through the strong influence of the Coreish,
they stood firm; but they were almost alone. Here and there some
few tribes, under loyal, or, it might be, temporising, chiefs,
maintained the semblance of obedience; but they were hardly
discernible amidst the seething mass of rebellion. Amru, hurrying
back from Omân (whither he had been sent by Mahomet as
ambassador at the Farewell Pilgrimage), witnessed the whole of
Central Arabia either in open revolt or ready to break away on the
first demand of tithes, and his report filled the citizens of Medîna with
dismay.[16] In truth, Islam had never taken firm hold of the distant
provinces; and as for the Bedouins, Mahomet had himself had
frequent cause to chide their fickleness. It was fear of punishment,
and the lust of plunder, rather than attachment to the faith, which had
hitherto held these wild sons of the desert in bondage to the Prophet.
The restraints and obligations of Islam were irksome and distasteful;
and now, on Mahomet’s death well rid of them, they hoped to return
to their lawless life.
As report after report came in of fresh
defection, Abu Bekr could but instruct his Demand for exemption from
tithes refused by Abu Bekr.
officers to hold on where they were able
with the loyal few, hoping to tide over the crisis till the return of
Osâma’s force. For the immediate defence of Medîna he took such
measures as were possible. He called in all that remained of the
faithful tribes in the neighbourhood, and posted pickets at the various
approaches to the city. The turbulent tribes in the near desert to the
east were the first to assume a threatening attitude. The Beni Abs
and Dzobiân massed there in such numbers ‘that the land was
straitened by them,’ and they parted into two bodies, one at
Rabadza,[17] the other at Dzul Cassa, the first station from Medîna
on the road to Nejd. The false prophet Toleiha sent his brother with
men to help them; but they still vacillated between the claims of the
pretender and Islam. At last they bethought themselves of a
compromise. They sent a deputation to Abu Bekr, offering to hold by
Islam and its ritual if only they were excused the tithe. The strangers
bearing the message were welcomed by the chiefs of Medîna, but by
the Caliph their advances were indignantly rejected. He would relax
not a tittle of the legal dues. ‘If ye withhold but the tether of a tithed
camel,’ said Abu Bekr, bluntly, ‘I will fight with you for the same.’ With
this refusal they retired, and also with the intelligence that the city
had but few defenders left. Now was the time, before the army came
back, not only for plunder, but to deliver a decisive blow. Abu Bekr,
foreseeing this, redoubled his precautions. He strengthened the
pickets, and set over them the chief men who had remained with him
—Aly, Zobeir, Talha, and Abdallah ibn Masûd. For the rest of the
people he appointed the Great Mosque a rendezvous. ‘The land hath
rebelled against us,’ he said, ‘and they have spied out our
nakedness and the weakness of our defence. Ye know not whether
they will come upon you by night or come upon you by day, or which
of you may be first attacked. They verily hoped that we should have
accepted their offer, but we rejected it. Wherefore be vigilant and
ready.’
And so it came to pass. They tarried
but three days, when a surprise was Attack on Medîna repelled.
attempted from Dzul Cassa. The outposts
were on the alert, and kept the assailants at bay while the main
guard was hurried up from the Mosque on camels. The Bedouins,
hardly prepared for so warm a reception, fled back upon their
reserves. They were pursued; but the camels of the Moslems, being
used only to draw water for the fields, took fright at a stratagem of
the enemy, and turning, fled back to the Mosque.[18] There were no
casualties among the Medîna troops, but the rebels were
emboldened by the flight of their opponents. Abu Bekr, anticipating a
renewed attack, called out every man capable of bearing arms, and
spent the night in marshalling his force. Next morning, while yet dark,
the Caliph himself led out the little band in regular array, with a
centre and two wings.[19] The enemy were taken by surprise at early
dawn, and as the sun rose were already in full flight. Abu Bekr drove
them with slaughter out of Dzul Cassa, and, leaving a portion of his
little force as an outpost there, returned with the rest to Medîna.
The affair was comparatively small, but
its effect great. As failure would have been Good effect of the victory.
disastrous, perhaps fatal, to Islam, so
victory was the turning-point in its favour. The power of the Prophet’s
successor, even without his proper army, to secure the city and beat
off his assailants was noised abroad. And soon after, the spirits of
the Moslems rose as they saw certain chiefs appear, bringing in the
tithes. The tribes they represented, to be sure, were few in contrast
with the apostate hordes; but it was an augury of brighter days to
come. Safwân and Zibricân, chiefs of two branches of the Beni
Temîm, and Adi son of Hâtim from a loyal branch of the Beni Tay,
were the first to present their legal offerings to the Caliph. Each was
ushered into his presence as an ambassador. ‘Nay,’ said Abu Bekr;
‘they are more than that; they are Messengers of glad tidings, true
men, and defenders of the faith.’ And the people answered, ‘Even
so; now the good things that thou didst promise are appearing.’
Tradition delights to ascribe with pious
gratitude the preservation of Islam to the Saving of Islam due to Abu
aged Caliph’s faith and fortitude. ‘On the Bekr.
death of Mahomet,’ we are told, ‘it wanted but little, and the faithful
had utterly perished. But the Lord strengthened the heart of Abu
Bekr, and stablished us thereby in the resolve to give place, no not
for one moment, to the apostates; and to say but these three words
—Submission, Exile, or the Sword.’ It was the simple faith in
Mahomet of Abu Bekr which fitted him for the task, and made him
carry out the law of his Master to the very letter. But for him, Islam
would have melted away in compromise with the Bedouin tribes, or
might have perished in the throes of its birth.
 CHAPTER IV.
RETURN OF OSÂMA. EXPEDITIONS FORMED AGAINST THE
APOSTATE TRIBES THROUGHOUT ARABIA.

A.H. XI. Sept.—Oct. A.D. 632

Osâma at last appeared, and Medîna,

for two months left unprotected, was Osâma’s return. Jumâd II.
relieved from further danger. The army a.h. XI. Sept. a.d. 632.
returned laden with booty. The royal Fifth was delivered to the
Caliph, and by him distributed among the people.[20]
Abu Bekr lost no time in now following
up the advantage he had gained over the Expedition against Beni Abs
and Dzobiân.
Beni Abs and Dzobiân. Driven back from
Dzul Cassa, they had retired to Rabadza, and vented their anger in
destroying by cruel deaths the faithful followers of the Prophet still
left amongst them. Deeply moved at the fate of these confessors,
Abu Bekr took a solemn oath that ‘he would by the like deaths
destroy as many of them as they had slain, or even more.’
Putting Osâma in command of the city,
and leaving the army there for a little while Abu Bekr chastises the rebel
tribes at Rabadza.
to recruit, Abu Bekr took the remaining
force and marched again towards Rabadza. The chief men
expostulated with him on going forth to fight in person. If a
commander were killed in action, his place could easily be filled; but
if the Caliph fell, their head and ruler would be gone. ‘Nay,’ replied
Abu Bekr; ‘but I will go forth, and will be your comrade even as one
of your own selves.’[21] So they marched on, and coming up with the
enemy at Abrac, completely discomfited them, killing some, and
taking others prisoners. The Beni Abs and Dzobiân fled to Toleiha,
and joined his army at Bozâkha. Thereupon Abu Bekr confiscated
their pasture-lands, and declared them to be for ever a public
domain reserved for the stud and camels of the State. On eventually
submitting, they found themselves thus debarred from re-entry; but
this was of comparatively little consequence, as they had, in the end,
ample compensation in the conquered lands beyond Arabia. After
some days spent at Rabadza, the Caliph returned to Medîna.
The army by this time was refitted. The
tithes had begun to come in from many Islam must be reimposed on
neighbouring tribes in token of submission. all Arabia.
Medîna was no longer in peril, and the citizens breathed freely. But a
heavy burden still lay upon the Caliph. Islam was to be the faith of all
Arabia;—‘Throughout the peninsula there shall be no second creed,’
was the behest of Mahomet on his death-bed. False prophets must
be crushed; rebels vanquished; apostates reclaimed or
exterminated; and the supremacy vindicated of Islam. It was, in
short, the mission of Abu Bekr to redeem the dying Prophet’s words.
With this great purpose, Abu Bekr went
forth a second time to Dzul Cassa, and Eleven expeditions
there summoned the whole available despatchedof Arabia.
to different parts

forces of Islam and all the loyal chiefs

around him. He divided them into eleven independent columns, and
over every one appointed a distinguished leader, to whom (following
the example of his Master) he presented a banner. Arabia was
mapped out, and each detachment given a province to reclaim, with
marching orders, where to begin and what course to take. Thus
Khâlid ibn Saîd was named for the Syrian border; Khâlid ibn Welîd
was to subdue Toleiha; and Ikrima with Shorahbîl, Moseilama;
Mohâjir was sent to Yemen; Alâ to Bahrein; Hodzeifa and Arfaja to
Mâhra; and Amru against the Beni Codhâa. And so by this great
scheme, in course of time, no spot would be left unconquered. The
troops retained at home were few; for few were needed now.[22]
Having despatched the various
expeditions, Abu Bekr returned to Medîna. Proclamation summoning
apostates to repent. Oct.,
There his first concern was to publish a a.d. 632.
summons to the apostate tribes,
commanding them everywhere to repent and submit themselves, on
which condition they should be pardoned, and received back into
Islam. Such as refused would be attacked, their fighting men cut to
pieces, and their women and children taken captive. This summons
was sent by the hand of envoys to every province and rebellious
tribe. The Adzân, or call to prayer, was to be the test of faith; if that
were heard and responded to, good and well; if not, the people were
apostate, and as such to be attacked.
Abu Bekr never again left Medîna to
lead his troops. Some say that afterwards Abu Bekr did not again go
he regretted this; but it is not likely that he out to fight.
did so. Medîna, where he continued to reside, was his proper place.
From it, as a central point, he was able to direct the movement of his
commanders all over the peninsula; and with operations in so many
different quarters to control he could not have been better situated.
It is more open to remark that none of
the more distinguished Companions of the No chief ‘Companion’
Prophet were appointed to commands. appointed to a command.
The same was the case with Omar, who was known to say that he
purposely refrained from nominating them to any government, both
out of respect to their dignity,[23] and also to strengthen his own
hands by having them about him as advisers. This latter reason may
also well have weighed with Abu Bekr, who used to take counsel on
all important matters with the leading Companions. Still, it is singular
that men like Aly and Zobeir, who took so prominent a part in the
battles of Mahomet, should now altogether disappear from
operations in the field.