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....


Filet-o-bitch RPh said...

I think this is one of the few times a shot of morphine for that poor man is just what the doctor should have ordered. :)
Are you going to show us your Puck costume?

Patient Anonymous said...

Hey, nice to see you back...sorry I'm a bit late in stopping by.

And yes, I knew what a frenulum was. Ouch.

I just went through that combo for conscious sedation for an upper endoscopy and colonoscopy and was surprised at how well it worked (I have had problems with upper endos in the past.) Was quite out of it.

deputydawg said...

Hmmm.Can remember aninebriated chap attending with his girlfriend in the wee small hours with the same injury.It was horrendously busy and he was left in the suture awaiting repair to his badly torn frenulum.However, one poor nurse found this chap and his girlfriend-obviously overcome by the occasion- "going at it" doggy style on the suture room table.Very messy!!!

Faith Walker said...

I caught some patients having sex in the toilets last week.


DrShroom said...

I've been lucky enough never to catch patients "at it"
But I'm thinking frenulum guy can't have been in that much pain... or maybe he liked it?