NFR

More pontificating on the matter of who should or shouldn't be resuscitated, and more importantly who makes the decision.
Frankly, and I'm thinking my opinion will verge on the wrong side of 'PC', it seems like a big ol' storm in a teacup to me. But the public do worry a great deal about it. Fair enough, I guess. There seems to be an over-riding fear that one will go into hospital, and be written off as a no-hoper by a wet behind the ears junior staff member, possibly just so they don't have to get up in the middle of the night and jump up and down on you.

That could never happen, right?

Not any more. God forbid we give our junior staff any responsibility. Or assume that they have any nous at all, after six years of medical training.

And now they want to let nurses make the decision...

Fine. Good. Why shouldn't they? It has been my experience that people who shouldn't be making important clinical decisions generally don't want to.

I guess times are always changing, but one of the bigger differences between the way doctors and nurses function, in this country at least, seems to be the level of inter-professional support. While medics are only too happy to moan about each other, often to each other's faces, or behind their backs, if necessary, we usually back each others decisions to the public. Nurses, on the other hand seem to distrust each other, and rarely seem to stand together; on anything.

So I always felt, even as a junior Shroom, that when I made decisions by myself, they would be supported by the rest of the Firm, provided I had a robust justification for them. Nursing staff seem to have a morbid fear of overstepping their boundaries. This seems to be crystallised in the current climate of rigid adherence to protocol.

This is not a criticism, but suggests to me that many nurses would rather not make a resus decision, unless there were strict guidelines about how to do so. Not because they aren't capable of making a well informed reasoned decision, but because if it became controversial, their colleagues would hang them out to dry.

From day one on the floor, I was making life or death decisions for the patients in my care, especially decisions about resus status, and frequently late at night, on my own, without consulting anyone. Should I have been? I suspect most people would now say not. But that was the way things were; and I like to think I made appropriate decisions - most of the time. Where it turned out my Boss differed, in the cold light of day, his reasoning was calmly explained, and the decision reversed. And I learned a bit more about how these decisions were to be made in the future.

So... who should make these decisions? Anyone who's prepared to, I say. Stand up, and be counted. Someone's got to...

Flatback Caper

I think, more or less, this blog is a year old today. Woo-Hoo.
There's probably some naval gazing to be done about this... but later.

Nights are almost done; for this run, anyway. Although I'm on again next weekend. My rota has seem me working a one in two lately. I'm not sure why, but shit happens I guess. Next weekend will be my fifth on in eight. Old school. Love it.

I think I've kinda missed Hallowe'en, although we had a few freaks in last night, including one young lady wearing the shortest skirt I have ever seen. I know I'm getting old now, because my first thought was: My belt is thicker than that, followed by: I bet she's cold. I was impressed by how adeptly one of my SHOs worked the board to ensure he ended up seeing her...

Continuing my musings on parents, I saw a fella, who I'm guessing was in his 30s, admitted after a fight. He had sustained mostly superficial wounds, and I think the damage was more psychological than anything - certainly his life was never in danger - but his dad, a man of 72, sat with him all night. Possessed of quiet dignity, this softly spoken man sought me out often to enquire after his son, and I did my best to reassure him. I was struck by the way he would quietly step aside from time to time before returning to his son's side. He used these 'asides' to surrender to his own feelings, small tears breaking through his defences for a few minutes, before he'd cuff them away, recover himself and go back to his son.

I guess we never really grow up while our parents are still around

A Bagful of Eddie

Death by Tray

You Got Bananas? Got Bananas?



Covered in Bees

Fiddlestix

Normal service resumed

Unknown male, early middle-ish age, non Caucasian ethnicity, found down at the ferry port. Agitated, apparent right sided deficit.

Examination reveled a well looking male, agitated, but not combatative, clammy, but warm at the edges. Normal pulse, BP sky high, heart sounds normal, chest clear, abdo unremarkable.
Leftward deviating gaze, left pupil blown - only transiently, as it turned out. No other gross neurology.

There's a list of differentials as long as your arm for this guy; but he smelled like a brain bleed to me.

It took a while to convince my gas passing colleagues, while we ticked off some of the more obvious and easily treatable ones. With no improvement, he won a long dark walk to the scanner, and we irradiated his brain.

I found out later he's 41. There's no joy in being right, either...

Sad-Eyed Shroomy of the Lowlands

It seems most of what I write these days is apologies for not writing.
Sorry.

My mood has been lower than usual of late. Work, money, work, personal life... blahblahblah.
I'm still disappointed my life isn't quite ER. Ah, well...

This month has been PICU month. I'm due a 3 month Paeds secondment, but it hasn't been possible for me to do it all at once. So, I got a month. I haven't done any ITU for a while, least of all Paeds. So it's been a valuable experience, albeit perhaps not exactly what I thought.

Intensive care is an odd place; organised, controlled chaos, if you like. When I worked on adult ITU, I think it was then that the psychological trauma began to build up. Maybe. I found it very hard to see so many die. Especially the younger ones.

Now obviously in Paeds, they're all young. But it seems to me that few of them die. Which is nice.

Instead, what I have found challenging is watching the head injuries. The ones I've seen tend to be older - in their teens - and were usually on the wrong side of a moving car. They have non-operative CT scans - no large extra-dural haematomas to be hoiked out by my neurosurgical brethren. But their brains are tight.

Recovery is slow. Slower than I'll know, as I haven't seen the neuro-rehab ward. What I find frustrating is how non-specific we have to be to the parents. They'll probably survive, but we have no way of knowing how they'll survive.

It is the worst of things, and the best of things. I have never been more amazed by the strength of human spirit than I have watching the parents of these kids. I simply cannot imagine how it feels to have to come to hospital, day after day, and look at your son or daughter, previously so full of life, so vital, and look at them, pale and waxy, tiny in an adult's bed.
And keep smiling.

And once all the tubes are out - the ETT, the bolt, the EVD, the drips and all - they aren't better. They look around, blankly, their limbs flailing. Trapped in a body that won't obey them. And still mum and dad come in, holding the patient's hand, lying in bed with them, holding them tight. No parent banks on having to watch their adolescent be nursed in an adult nappy, on having to help bed-bath them. But they do it. I don't know where they find the strength.

And then... sometimes they just stop flailing, and start looking around. They start speaking. Their movements become appropriate. A 'high-five' has never meant so much to me...

Clearly, this is not the end; but maybe the end of the beginning? Or the beginning of the end? Something like that...

There really is hope. Who'd have thought?

Idiot Wind

I meant to write this up a few days ago. I was out with a few friends, one of whom revealed he reads this from time to time. Clearly not very frequently, as he was complaining I'd not written anything for months. Anyway, I've been meaning to write for a while, but everything seemed very bleak, and I wasn't sure self pity was what's called for.



I'm on the Paediatric ICU for a month at the mo', which is frankly terrifying. More of that later. Most of the cases I've seen in the ED have been either 'mundane' or depressingly bad news. Possibly more of them later, too.



A few days ago, we got a all too familiar call. A gent in his 70s had been found collapsed by his wife in the bathroom, in the middle of the night. The Ambos reported him agitated, irritated. "Irritated" has a particular medical meaning. It, usually, does not mean that the patient is in a bad mood. The implication is that there is something irritating the patient's brain, and that there behaviour is irrational, disturbed. The irritant is usually blood.



I am sure you don't need me to tell you this is not ideal.



This fella fitted the pattern. Lights on, no-one home. Large bruise over his right eye. Not much else to see, but high blood pressure. Forcing blood into his tight swollen brain. The whole thing smelled grim.

The usual pattern - a modified rapid sequence induction, with intubation; waking a groggy radiologist to fix the scan; the long dark walk to the scanner.

In the meantime, there's always the family. I still hate this bit. I guess it's alright. Once I start enjoying it, someone needs to take me out back and shoot me.

Most-times, the family know. They may not be ready to accept it yet... but they know. We talk through the possibilities, the 'maybe's, the 'might-have's, and the 'what-will-be's. It's difficult, because in my heart, I know this guy's gonna have an huge bleed. I know I'm going to be back in here in half an hour, with the scan results, telling them there's no hope for a positive outcome...

And they know I know. We can see it in each other's eyes. I think I'm getting worse at lying with age.

So... scan is normal. Yup, normal. No bleed. Which doesn't mean he hasn't had a big fuck-off stroke. (And, yes, that's the technical term) It might just mean it's thrombo-embolic, and that we can't see it yet.

Will he wake up? Time to find out. My friendly gas man turns of his milk of amnaesia, and up he comes. We pull the tube...

There is the usual coughing and spluttering, and then his eyes... focus. He looks around, confused, and his words are husky, but he knows his name, he knows his date of birth. His neuro is exam is normal.

This case, which I knew was going to be a bleed, to be a disaster; which I knew was going to end in me ruining another family, was probably micturition syncope and a minor head injury. Well, minor-ish...

I go to see his family, and I have never been so happy to be wrong.

(There y'are J...)