Sunday, April 22, 2007

You Can't Always Get What You Want

Thus spake the philosopher Jagger.

Musing over my previous post, I am reminded of something that occurred when I was a HouseSurgeon at another DGH. The details are less well known to me, as I was just ScutBoy, but it illustrates the same principles well. I'm beginning to think that foremost among them should be "don't believe what you're told", no matter who tells you.

In this case, a patient was brought to the A&E (as was) having been 'found down' on a railway track. There was no suggestion that he'd been hit by a train - i.e. he was in one piece - but he was under a bridge. My understanding is that he was first assessed by a rapid response team. Two basic options present themselves:

One - he has jumped / fallen from the bridge above. Classification: trauma. Plan: rapid transfer, eager doctors waiting.

Two - he was walking along the railway track, and passed out here. Classification: Not Trauma. Plan: call some other guys to ship him to hospital; tell no-one he's coming.

The on-scene assessment was the latter.

He duly arrived in hospital labelled "collapse ?cause". No bother he can wait his turn. This was, of course, back in the 'good old days', when waiting really meant waiting.

He duly waited. After some time, the duty Senior HouseSurgeon was passing through the Department, and spotted said patient. She was of the opinion that he was entirely too white a shade of pale, and stopped to give him the once over.

One quick primary survey later, an open book pelvic fracture was discovered.

Much later an history of attempted suicide by leaping was discerned.
My memory does not extend to exactly what assessment this fella received on arrival, but it evidently didn't extend to routine re-assessment. Or did it? I genuinely don't know, bu somehow he slipped through the net, mostly because his initial label was along the lines of "he's o.k.", and it stuck.
On a lighter note, it was while working at this hospital that I had the pleasure of working on call over Christmas, and the A&E staff all dressed up for Christmas Eve / Day. Nothing beats the look on a patient's face when he opens his eyes post resuscitation, and the first thing he sees is a blond nurse dressed as an angel.

Saturday, April 21, 2007


Dropping the Ball
When something doesn't go according to plan, it's usually a system failure. There are rare occasions when someone pulls off an act of sheer banditry that couldn't be anticipated or mitigated by anyone else. But mostly, everyone fucks up a bit. I'm guessing most people feel the same way I do about this - everyone makes mistakes, but we rarely like to admit / talk about it. Mistakes in medicine are always a little bit higher stakes than in other jobs.
Personally, I've made my share of errors; I've learned from all of them, but the rude fact of life is that shit still goes wrong. Generally, I've got tickets on myself. I reckon I'm good at what I do, so when it turns out I haven't done it to my best ability, I feel shit about myself for days.
I guess it's the same for us all.
It's easy to write about times when you did something that worked, or that paints you in a good light. The reverse is harder.
I could imagine it might happen something like this:
Picture a man who is involved in a car accident. He is rescued by the Paramedics after some 30 minutes. They assess him as having sustained no serious injuries, and he is shipped to the local ED. He is boarded and collared, and assessed promptly on arrival. His spine is cleared, and no serious injury noted. He is left for formal assessment.
Several other patients arrive in the Department around the same time. One is apparently critically ill, and goes straight to resus, prolonging the wait of our fictitious patient.
He is eventually seen by a doctor about an hour after he arrives. He has no complaints, except of some pain in his knees, which he has grazed in the accident. Physical exam is unremarkable at this stage, barring the fact that he is cool and clammy. His pulse feels rapid, but of good volume. He is known to be in AF. The attending physician notes that he was given 20 mg iv morphine on scene, and attribute the beads of sweat on his forehead to this.
The patient is moved to another clinical area for monitoring. His first set of obs are done, after some 90 minutes. His blood pressure is borderline low, and his pulse still fast. An ECG confirms AF with a rapid VR, and slightly ischaemic picture. He complains of no pain, and his doctor wonders if the appearance might be the effect of the digitalis he is taking. Repeat exam is still unremarkable, barring ongoing clamminess. His doctor is slightly concerned by this. It can't still be morphine after all..? A period of observation is proposed; the patient declines, stating that he feels fine.
Anxiety growing, his doctor asks him to wait a little longer, and asks for routine blood tests and a fluid bolus to be given.
Something like an hour later, the patient looks worse. His BP is lower and his pulse faster. He now has abdominal pain - although his belly is still soft.
Now: 3 hours after arrival, he is moved to resus. Repeat assessment reveals some firmness of the rectus muscles. This will rapidly develop into a peritonitic picture.
Finally he gets a CT scan, and surgical consult. CT shows intraperitoneal bleeding, and he goes straight to theatre. Operative course is uncomplicated, and he recovers on ITU.
My guess is things like this happen all the time. In retrospect, the hypothetical patient was unwell for a while, but an unclear history and paucity of physical signs allowed false reassurance. That he waited 90 minutes before first formal nursing assessment didn't help. As I said, this was a fictitious example. The Shroom might learn from such a train of events however. If mechanism sounds high risk, it is, even if the patient looks and fells well. Never trust the abdomen - trauma is a frighteningly dynamic process. And, especially, even if you think you know you're shit, you probably don't know it as well as you think you do.
Like I said, this was just hypothetical, and I'm certainly not trying to teach anyone to suck eggs

Wednesday, April 18, 2007

Room Full of Mirrors

Nights again.

I still quite like them... tiring as they can be, I can't help but romanticise them a little. No actual romance, mind. A lot of limb injuries for some reason.
Fractured arms, wrists, shoulders and ankles. Lots of sedation, manipulation and plaster. Almost a good night at a special interest club.
One poor old soul has been given a grim diagnosis; one that we all knew was coming. One of those. An horrendous looking mediastinal tumour, with invasion around his spinal cord. I'm not sure what the exact diagnosis is, but it's clearly not going to be champagne and strawberries. As I've posted before, this sort of thing really takes the wind out of everybody's sails. I always wonder if we could have done more for these guys. Intellectually, I know this is slightly ridiculous, as they have presented with a diagnosis that will belong to a long standing pathology, but I still find myself wondering if the odd 30 minutes wasted in the ED will somehow turn out to be critical...

I singularly failed as an educator tonight. I took one of the SHOs to show her how to reduce a shoulder. There are a legion of ways of doing this; I attempted to talk he through a few, and then had planned to get her to do it. But in demonstrating procedure, I found myself saying "put your hands here, and then externally rotate, and..." **clunk**

Job done...
Ooops... sorry
I guess as mistakes go, it's better than pulling the arm off, but I still feel bad. It reduced the educational benefit to nearly zero. I say nearly zero, because I was able to produce a spectacular demo of the effect of nitrous oxide ('laughing gas').
We generally use morphine and midazolam for our procedures done under conscious sedation. It can be supplemented with nitrous oxide; I had commented that many of my peers dislike it, because they find it increases disorientation. Our patient had a history of previous opiate and benzodiazepine use, so I had thought to supplement her with nitrous. Sure enough, after 2 minutes, she was smoking the pulse ox monitor, complaining that she couldn't empty the ashtray, and drinking from the hudson mask.
Ah, drugs....
My last patient was a painful one. he admirably demonstrated the 'all mouth no trousers' phenomenon, however. He was wheeled into the Department, covered in blood, laughing and shouting. Waving his blood stained hands about he was shouting, mostly at the female staff:
"Darlin'! Oi! Darlin'! Guess what I done! Go on! Guess!"
"Nah, I ain't tellin' ya! You don't even wanna know what I done, innit!"
What had he done? Torn his frenulum. This, for those not in the know, is the piece of skin on the underside of the glans penis, attaching it to the foreskin. It is essentially identical to the frenulum in the mouth attaching upper lip to gum. Sometime referred to as the 'banjo string'
I'll leave it to your imagination how he said he did it.
Tearing it is quite painful, and bleeds. A lot.
I should know.
His brash, loud exterior changed when I explained what we needed to do. The sentence contained the words 'needle', 'injection', 'penis' and 'stitch' in various order. Also 'local anaesthetic' and 'sting quite a bit'. It wasn't a warm, fuzzy sentence. No champagne and strawbobs here, either.
The repair was a breeze, and his attitude changed again. He refused to stand up, claiming he felt weird - not unreasonable, all things considered - but did want first to be brought gas-and-air (more nitrous) and second to be wheeled out for a cigarette. Both activities guaranteed to make you feel less weird...
One quick Hb check and a set of postural BPs later, re-assured that he hadn't left too much of his blood behind in his bedroom, we sent him packing. On a no-sex embargo.
I half expect to see him back before the week is out....

Saturday, April 14, 2007

Bryter Layter

And so it goes on...
I still can't seem to find anything to write. For various boring reasons, I haven't really been in the mood. At least partly I'm stuck between the desire to write intelligent relevant comment - not least because I want to impress my small readership - and what feels like my need to just witter inconsequentially...
So what follows is mostly the latter. Be warned.
I've been off a few weeks, sort of, but I don't feel any more relaxed. Work continues to bug me. Which is shit, frankly, because sometimes it feels like all I'm good at. I think it speaks of a deeper self loathing because I'm so disorganised. Laissez-faire, you might say, if you were as pretentious as I am.
My best friend has returned from Africa t get married. I was honoured to be asked to be one of his best men (3rd time as a double act for me... is this fashionable, or am I not quite good enough to pull it off alone?) Clearly I'm pleased about this, but so far haven't really contributed anything... I'm actually embarrassed at how little help I've been. This isn't helping my self esteem.
On a lighter note, I discovered another medical blog today, which has brightened my day a bit. Especially a post about the dreadful habits men have of observing their female colleagues a bit too closely during CPR. (However, I'm confident that scientists will discover a gene that codes for looking down tops, and then we can blame it all on that.)
I'm going to try and ease my aching brain with a visit to my God-Daughter. Lunch with her folks always helps ground me a little, which can't be a bad thing. Then, this evening, I think I'll get drunk somewhere and make a fool of myself. Another great leveller.
I'm moving jobs in a couple of weeks, so expect exciting drivel about my scramble to pass my end of year assessment, and then the crap inherent in moving hospitals.
Oh, and I've gotta dress as Puck for the wedding. Costume ideas, anyone? (I quite want to wear an 18th century frock coat, but can't quite seem to make it relevant...)