Monday, December 11, 2006

The end is in sight

Or at least I hope it is... a few more hours, then I can snooze into my 'day off'.

Those of you with even a passing interest is MMC, should look here. Very amusing, and my thanks to Dr Rant for shedding light upon it. I continue to be generally dismayed with what I think the future holds for medicine, medical training and Emergency Medicine in this country. I'm not sure where it went wrong, but I can't shake the feeling that a disaster of epic proportions is looming.
Being, as I am, something of a sceptic / cynic / old school practitioner, I have always been quick to get a bee in my bonnet about alternative therapies. In general these remedies or treatments have no real evidence to support their use and efficacy. However, I accept that some of them do work... but most of them are bollocks.
Anyway, the reason I mention this is that I have stumbled across Le Canard Noir, a feathery advocate for real science, intent on rooting out the charlatans among us. He's worth a look. (Although I was disgruntled to discover that the Shroom has a relatively high canard count himself. Well, no-one's perfect...)
Tonight has been on the grim side. It was busy again. The sort of soul destroying busy, that welcomes you into the department with 6 waiting and three booking in in majors, and a full waiting room in minors. One side effect of the four hour target (all Hail!) has been a change in people's expectations. Now that waiting times are down, almost any delay pisses them off. And it is hard for people to see beyond their own crisis - which is natural enough really. But when several 'sickies' are in the Department together, everyone else kinda has to fend for themselves for a bit. Which they don't like...
---So, my last patient this morning was a young girl with meningitis. In truth, it was more like meningococcaemia, but for non-Medics that's really semantics. Of course, it makes a difference to how you treat 'em, but Mum doesn't need to know that.
Anyway; as with so many of these cases, she got sick really fast. In a matter of hours. By the time I arrived she looked dreadful. Really flat, and listless. As if all her energy was occupied just being. She had proper bags under her eyes, which is always grim in a child, and was parchment white. This is not the same colour as sheet white. There's a slight tint to it, as if she was sheet white, then someone gave her a sepia wash. (This is also one for the list of colours you're glad you aren't)
Actually her numbers were never that bad - pulse, BP, sats, CRT, resps... they were all more or less normal - but she was off away somewhere else. Lights on, no-one home etc. As if in addition to just existing, she couldn't allow for the existence of anyone else. She seemed completely unaware of her surroundings. And of course, she had The Rash. I find the non blanching rash of meningococcaemia particularly sinister. Especially when you see it spread right in front of you.
Well we dosed her up with antibiotics, and I here she's doing better today. She's still not focusing properly, which makes me a little anxious, but time will tell...
Today, almost at the same time, I had my attention drawn to two patients. The first was in his 80s, and had had a 'collapse' at home. The presenting complaint "collapse ?cause" is generally a real heart-sinker for the British emergency physician. I'm not sure what the equivalent would be across the pond, but many of these patients are GOMERs, or aspire that way. Anyway, patient A (names have been changed, etc...) was not a GOMER. He had a history of blackouts, thought to be cardiac in origin, and had, it seemed, had another one. He had initially been quite chatty at scene, but slowly become less so. The crew who brought him in had left him on high flow oxygen, and so it was that he was found by my SHO in the grips of CO2 narcosis.
---ECG showed right bundle and chest radiograph confirmed significant pulmonary oedema, with bilateral pleural effusions. So, in essence, his body had turned his lungs into massive sponges; so much so, that water was collecting outwith his lungs as well. Some Lasix and GTN will dry him out, thinks Shroom, and BiPAP will rid us of that wicked carbon dioxide...
Meanwhile, on the other side of resus...
---Enter patient B, also in his 80s, who was minding his own business at home, when he began to fell light headed, dizzy, clammy and nauseated. When this feeling got worse, he called the Ambulance. They found his pulse to be 25. (This, as I'm sure you all know, is one of the many pulse rates you should be glad yours isn't)
On arrival, during his initial assessment we lost him... just for a moment, 15, maybe 30 seconds.
Then he came back. Good blood pressure, alert, comfortable. Pulse of 20.Sporting...
I gave him atropine; little by little, looking hopefully at the monitor. Watching. Waiting. It didn't work. 12 lead showed a junctional brady. I guess his atria, or more specifically, his SA node, just gave up the ghost. Anyway, but for the pulse of 20, I was happy with him. So I called the Magicians to admit and pace him. I hoped he wouldn't need transcutaneous pacing.
A bit later, when the clever docs came to see what fun we were having, it all went a bit wrong. First they said - see patient A; he has had a heart attack, and you have done nothing. This was very distressing, for patient A was perking up, and I had been feeling pleased with myself.
To cut to the chase, they were wrong. His ECG, which I had thought right bundle, and they a posterior infarct, was indeed right bundle. The Shroom, and indeed patient A, breathes again.
But patient B; poor patient B.
He had used the oldest trick in the book, and gotten unwell, while I wasn't looking. His pulse and BP were still the same, but his belly had blown up and he was getting all sorts of pain in his back.
---Many docs came to see him, including surgeons.
---Many hushed and whispered conversations.
---All ended with grim shaking of the head.
(Dammit, Jim, it doesn't look good.)
Mrs B took it hard. She was now seeing her husband of more than 50 years get sick right in front of her. I'm still not sure what the primary pathology is, or was. But it made a liar out of me. I told him, and Mrs B, that it was just his heart, and that the clever doctors could fix that, with wire and an box of electrical tricks. And I was wrong. Which sucks. Although not as much as it does for them, eh?
---Anyway, my point in this, before I got morbid, was that, while this was all ongoing, in minors was a lady who had been unfortunate enough to be bitten by her guinea pig. A small uncomplicated wound, with minimal bleeding. on her finger. Large trials suggest that these wounds do better if left alone (i.e no stitches) and our policy tends to be to leave animal bites alone. If it really needs closing, it also needs debridement etc. Anyway - it did not need stitching.
So while we were ministering to patients A and B, her waiting time increased.
I was asked several times about her, and advised that no suturing would be required; if bleeding was a problem, direct pressure with a finger should be tried first. (Shroom's blunt haemostat).
But this was not good enough for her partner / friend / whatever. He kicked up all sorts of stink, about the wait, and especially about the fact that we weren't going to stitch it. Pa Shroom, who was a proper knifeman, didn't believe in suturing any wound unless bleeding was an issue. (That is perhaps a slight exaggeration, but he certainly had a liberal policy of not suturing...)
In fact this fella insisted we suture her finger. He seemed to be labouring under the impression that in the same way as patients can refuse treatment, so they can compel me to treat them; he was most put out to discover that the decision about medical treatment is usually made by a person with a medical degree. In short, we wanted to bring the upstart round to resus, to try and get some perspective on life, and on the difference between waiting a bit longer for your tetanus shot, and getting the chance to be with your partner of 50 years at the very end.
But I'm not sure he would have understood.


A Bohemian Road Nurse said...

This is what you do on nights such as the one you described: You stand up straight, click your heels together three times, and recite over and over: "There's no place like Podunk...." It works for me sometimes. (Feel free to substitute your own choice in the place of "Podunk".) (And it does tend to work better when wearing Ruby Slippers...)

Sid Schwab said...

Good work on the little girl. Had you missed it for any time at all, she'd not have made it.

I hated to see animal bites sewn up, except in the loosest of fashions to maintain a semblance of cosmesis, which was rarely necessary. Reaction to not sewing up such thing is a little (only a little) like "what do you mean you're not going to remove the bullet??"

Sid Schwab said...

Well, I guess I should modify my statement: puncture type bites, or little tears. Take a child chewed on by the neighbor's pit bull, and of course you need to sew it up.

DrShroom said...

Thanks. And I heartly concur with what you say about bites. Of course some need repair, but that should be done formally, with proper lavage and debridement. Tiny nips from guinea pigs don't come into this category.
Re: the little girl; thanks, It's always nice to do something worthwhile, every now and again.

DocBellaise said...

GOMER= Get Out of My Emergency Room, House of God. I'm reading it now. Great post. Guinea pigs scare me a little. That's all. Good luck.