Tuesday, January 23, 2007

Good Times, Bad Times

Something of a mixed bag.

Somedays, I feel like I'm flying at work - not literally, you understand - but in that everything I do works, goes smoothly and results in fantastic relief for all my patients. No matter how complex the problem, or how many patients the God of ED lobs your way, I manage them all, slickly, with aplomb, leaving everyone wanting more. (Who was that masked man... **swoon**)

Somedays it feels like I'm swimming through treacle, carrying breeze blocks chained to my balls.

I must admit, I think I thrive on stress. When the Department is busy, it gives me the chance to pretend like I'm in ER, dashing about, shouting 'important' orders, saving lives. It's an ego boost when the nurses refer the complex cases, or sick patients to me.

The Arrogant Shroom knows it's because I'm just that damn good.
Realist Shroom knows it's because I'm the only senior on the floor.

Busy days give Shroom the opportunity to fly, wowing everyone. (In his own mind, in case this isn't clear - Ed.) On a bad day I'm prone to decompensate. Today was one of those days. The Department filled up pretty quick with patient after patient needing close attention, and after I had three on the go, and the Charge Nurse pulled me to one side to tell me there was someone sick as a dog in Resus, I was ready to tear my hair out. Fortunately several of my bosses were about, so I had some support, but Arrogant Shroom doesn't like to have to admit that he's only human, and can't single handedly cure the entire South Coast.

So, today we had:
--- 96 y.o female, probable stroke, GCS 7
--- 86 y.o female, collapse, hypothermic, low GCS
--- 18 y.o. male, fall, with head, arm and leg injury
--- 81 y.o female, found collapsed at home, possible stroke, possible MI

These guys didn't all arrive at the same time, but they were all here at the same time, and all ended up with the Shroom as their Doc du Jour. It felt a bit like fighting the Hydra, chopping off heads left, right and centre, only for more to spring forth. Fortunately I have the support of many excellent Docs and Nurses, not least to stop me getting an over-valued idea of my own self-importance.

The last two patients in my run of six affected me the most. One was an elderly chap, who had collapse in the barbers, and arrived GCS 3. We worked on him a bit, and he perked up to GCS 7. If he was another stroke, not much was on offer. These cases do badly, and end up with left lateral and TLC (tender, loving care) until it's their time to go. If it's a big bleed... well, you never know. The Boss couldn't find enough clinically to call it a stroke, so we headed for the Doughnut of Doom.

For those not familiar with head CTs, all that white stuff in the middle of the picture is blood; and none of it where it should be. Unsurvivable; unsalvagable; do not pass go, do not collect £200. Time for bed, sir.

We had to call the fella's wife in. Sometimes, when the patient is elderly, their spouse - also elderly - has no idea what's going on. I feared the worst in this case, as the lady had no-one to come with her, no support, no-one to lean on. When I stepped in to see her, she was one step ahead of me - had heard it in our voices, she said. Her strength in the face of the horror I unburdened onto her took my breath away. To lose your soul mate of decades in the blink of an eye... I can't even begin to imagine it. This woman's quiet, dignified grief made me ashamed, and I'm not sure why. But I'm glad we had our diagnosis, and I'm glad we could keep him alive long enough for her to see him one last time. Too many people shuffle off with only people like me for company.

The second case has a brighter outcome, so far. Another elderly chap, this time with severe chest pain. Initial ECG, in the back of the Ambulance was non-diagnostic. Then, as he was rolling up outside, that all changed. His ST segments pulled up in II, III and AvF. Barn door inferior MI

Time for a spot of thrombolysis. For this patient, the agent of choice, in this hospital, is the venerable streptokinase. The patient was understandably shaken when I told him what was a'goin' on. But he got with the programme, and we plumbed him into the magic clot-busting elixir.

I fucking hate streptokinase.

Half an hour later, they called for me. The patient was sitting up on the trolley - pale, clammy and gazing off into the distance. I can't quite put it in words, but I've seen this look before. I'm sure all medics have. 'The lights are on, but no-one's home' is the closest I can get. His gaze began to drift off, and his breathing became stertorous, almost as if he was trying to blow bubbles.


No reply


Fuck all.

Shit. This guy is stroking out. Right here. Right now. (Activate drama queen mode)

Convinced h was about to arrest, I asked someone to get the boss. I figured if he went, we'd need to scan him quick - if we got him back. His pulse, BP and sats were actually holding up, but he wasn't doing much to keep things that way. I dumped him flat, and got out the BVM, all the while calling his name, and trying not to shit myself.

(This is high on the list of ways NOT to look professional, and co-incidentally, high on the list of things to avoid doing at work)

Sure enough he became apnoeic, for about a minute - felt like an hour - and then came round. Whilst I was overjoyed to see him awake, and alive, this is tempered by the fact that he now thinks I'm a fucking halfwit, as he feels fine, and can't understand why I've got a mask clamped to his face, screaming hysterically.

At that point, the door bursts open - "I couldn't find the boss, so I got two SHOs!" God love my SHOs, but two junior docs, does not equal a consultant.

Subsequently, our patient's ST segments resolved,and he started feeling better. We have commended him to CCU.

I fucking hate streptokinase.

A light note to end on. What my American colleagues would call the Throckmorton sign, a phenomenon we refer to as Percy Pointing to the Pathology. False in this case, but a nice sign, nonetheless.


ERnursey said...

I hate thrombolysis, I sure am glad that our hospital mostly just takes the MI's right to the cath lab. Love the reference to Throckmorton's sign LOL. BTW, don't discount yourself, the ER nursing staff knows who can handle the hard ones.

Patient Anonymous said...

I enjoyed this. You do good stuff shroomy, don't doubt it.

Medblog Addict said...

Nice x-ray.