Wednesday, May 16, 2007

As Good As You've Been To This World

Feeling maudlin today

Midweek blues, and everything that promised so much at the end of last week, seems to be vanishing in a haze.

So: Old jib from Shroom's casebook.

I don't think I've talked about this case before; apologies if I have.

Sometimes, you start with what looks shitty, and it keeps getting worse. I think this is harder to deal with that something that looks bad, and is simply bad.
When you deal with someone who looks really bad, and keeps getting worse, all the little promises you make to yourself, to the patient, to their relatives - all those minute fragments of hope you leave out, to keep it flickering, alive - they're all exposed as lies, oh, so quickly.

The start of a shift is bad for this. Especially in a busy Dept. That's when, through no-one's fault stuff slips through the cracks.

I came on to a particularly hectic department. Understaffed, undernursed, just barely keeping their heads above water. First thing I saw was a patient in the 'high - dependency' bay. (It's monitored, and visible from the Nurses / Doctor's station. The trolley was in Trendelenburg. (Head down).
Never a good sign.

All about me staff are rushing urgently, all busy doing something... but not for this patient. This is briefly re-assuring; maybe a vaso-vagal? My eyes casually flicked up to the monitor, all at once taking in the profoundly low Blood Pressure and fast heart rate. I remember only then looking at the patient and thinking how young they were. Young and pale. Pale enough to be on one of Shroom's lists.

The history is typical for this sort of thing in Shroom's experience. A young 'un, brought in, walked in, with parent. Innocuous, non-specific history for a few days, finally developing a few sinister symptoms, provoking the visit. People who walk in can't be sick, right.


Eyeballed by the nurses out front, the patient is rapidly propelled 'round the back', or wherever your major treatment area is. Then something else happens, and they get left... it happens. The one's that don't, don't fulfill this sort of category.

Anyway, we booted this one to resus, and fired up the usual. Large bore access, oxygen, bloods. Fluids, fluids, fluids. Hot as hell, we chuck in broad spectrum antibiotics, and go rash hunting. Meningococcal sepsis finds itself high on my list of 'Diagnoses Not To Miss'. (As well, coincidentally, as my list of 'Illnesses Not To Be Afflicted With'.)

Clinically the picture is of septic shock, in a young patient. But how bad? Try to explain what's going on, serious but not too bleak. Yet.

Slowly, then in a rush, every test I did came back, the patients indices all wildly out of kilter, the case getting more serious by the second, and the response to 'simple' treatment unimpressive.

The source was revealed as a multi-lobar pneumonia. ITU were swiftly involved, and the clever medicines deployed, through big, ugly lines. And every few minutes I had to go back and explain that the situation was a bit worse than before, to unmask my lying optimism, to shred a bit more of he fragmented hope I'd thrown out.

As the patient left, I really thought it was all up. We had done all we could, they would do all that they could; but it wouldn't be enough.

It was.

Sometimes they do get better.


Joey said...
This comment has been removed by the author.
Joey said...

wow, good catch - any underlying weirdness leading to such a scary presentation in someone young?

agree totally that walking=not sick is a load of balls. similarly that young=well is also balls. once had to phone a GP for a friend who was sick while we were in halls in first year - first presentation of penicillin allergy, with full-on rash and tachycardia, he was delirious and couldn't stand up let alone walk the half hour to the surgery, we were only first year and didn't have a clue. receptionist said 'he was born in 1983, he can walk'. great.

GP told us when he finally arrived that if the same thing happened again we should say stiff neck, photophobia, vomiting, rash, and that would get someone's attention!

DrShroom said...

Ah to be fair, it wasn't really a good catch; everyone knew the pt was sick, just not how sick. As far as I know the diagnosis was nothing more outlandish than septic shock secondary to pneumonia, but haven't followed up why someone so young had such a severe dosing

Bongi said...

there is an art to breaking news to family. i always throw in worst case scenario, but also give a flicker of hope. sometimes a spark maybe. if things go south, they were at least semi prepared