Wednesday, February 06, 2008

Love In Vain

Unhappy post.

Somedays, it's all just shit. Sometimes, you do everything right, and its still shit; sometimes you make things a bit worse; somedays it's all your fault.

I'll have one from the top, and one from the middle, Matthew.

We have new SHOs starting today. They're all called something new know. FY2 or ST1 or something. SHOs of varying experience. I worked with a couple of them today, and they seem competent enough. A few of them rubbed one of my colleagues up the wrong way; I find this basically amusing. I will enjoy the soap opera that is the bedding in time.

Anyway: number one. A woman found by her son, slumped in her chair, not moving her left side. Several fits later she is at our door. Her blood pressure is high and climbing. She offers us no response, not even with determined teasing. Her ECG shows ST elevation, laterally. To my mind it all points to rising intracranial pressure. A bleed, I am sure of it. Blood coursing about her brain, irritating, inflaming. I call the intensivists. They are reluctant to intubate her; they shre my concern that whatever the injury, it will prove unsurvivable. But they will take her to the scanner for me.

The scan is unexpectedly unremarkable, but th radiation hasn't enlivened her at all. Her pulse and breathing become erratic; the duty Magician comes to visit. We are all very earnest; but it doesn't help our patient. She must be leftt to fight this fight alone. Her card is marked (the trial was a pig-circus), but we can't help her.

Next: a fella just old enough to be considered old. Difficult to gain a history from, as his shhort term memory does not reach much further back than 10 minutes ago. But he is in pain, his belly swollen, distended, taught. His pulse is weak, rapid, fluttering in and out beneath my fingers. I talk to the Surgeon; he does not want to see the patient; he wants to see the scan. We pump him with fluid, drive his pulse down, and his pressue up. His colour improves, and his edges warm, just a little.

I watch him for a while. He holds the line, he is stable. I know he is sick, I know the intensivists need to know, but I think I can wait until the scan is done. I don't think his airway is threatened. I tell myself the scan obviates the need for plain radiographs. I tell myself I can manage the transfer.

We don't normally transfer patients. Department workload is too great. I take my break, and one of the supernumary SHOs, and we take the transfer. It's a good learning opportunity; I've done plenty of transfers in the past. We'll be fine.

We are not fine. All the medics reading will be familiar with the adage that whatever ca go wrong, will go wrong; and if possible it'll happen on the CT table.

As soon as we put him on the table, he starts vomiting. It rapidly becomes effortless, and the patient agitated; he resists being on his side. While I am belatedly calling the intensivists, he loses his airway, and rapidly his pulse. We try to run a resus, but it's chaos in the scanner. Help is not slow in coming, and we get him back. I think clearing his airway was all he needed.

Well, that and a smidge of adrenaline.

The surgeon bows to pressure and comes down. We eventually get our scan; it shows all the wrong things. Bowel obstruction, probably from a tumour. Closer inspection shows gas in the wall of the bowel; dead gut; gas gangrene; the writing is on the wall.

I am at a loss to explain why I did not X ray this fella in the Department. I might have had my answer then, might have convinced the surgeon to see him upstairs, might have avoided the indignity, and squalor of a disorganised arrest in a basement CT suite.

Sometimes we just make bad choices.

The fact that they changed nothing, that this man's family would have been surprised, horrified, destroyed by the news of his impending death, does not excuse them. If nothing else we owe our patients the right decisions on their behalf.

And for all my wailing and gnashing of teeth, I'm trying to remember that it's not about me...


the little medic said...

I guess when there are bad days in medicine they sort of suck more than most careers.

As you wrote in your happy post, you just have to take the small things and when things are shit, try and focus on the good things, no matter how small they are.

Baby Blue Pyjamas said...

Wow, When i Said i would stay with the fitter i did not think it would be that bad.

I'm sorry for moaning at you in the staff room. You had plainly enaugh on your plate.

But Dr Shroom if i was rushed to resus i would want to hear the "If you would be so kind as to get me some -insert drug name- at your earlyest conveniance, aw ill get it". I'd know i was in good hands.

Pro et Contra Medic said...

TLM: Nice said.

If I may ask, when you said: ” Her ECG shows ST elevation, laterally.” Was that not STEMI?

DrShroom said...

Pro: I really hope not. It was a little odd looking, and the history didn't really support STEMI. Raised intra cranial pressure is one of the 8 or so things that can cause ST elevation other than myocardial infarct. Nonetheless, I let cardio know. They certainly weren't going to thrombolyse, and weren't keen on a trip to the lab either...

Faith Walker said...

I believe i've said this before shroom- but i'd let you manage by airway anyday!


911DOC said...

great posts. sick patients. you made time critical decisions that sound correct to me. i don't think your plain film would have changed things regarding the pneumoinstestinalis since i have only seen it once on plain film and i was lucky.

you are featured in my current post at mdod. hope you don't mind.

hope to meet you someday.

911DOC said...

obtw, nice 'stones quote.

Chrysalis Angel said...

I feel for the position and the weight those of you in the profession have to carry at times.

Katalia said...

Wow that's a horrible day.
I've had days like that in the CT room too.
Hope it doesn't happen to you again. :)

SeaSpray said...

I'm sorry that happened but you did your best at the time. You all have so much responsibility and have to make quick decisions.

adventures in disaster said...

First say aloud how damn thankful you are he arrested in the CT scanner and not the MRI. Ever try to code someone in there? You can't.Literally.
Second I know why you didn't get the flat plate. It's because the surgeon asked for a scan, I have noticed too that the moment a scan gets asked for no one wants to just seems like a complete waste of time and you know the surgeon will still make you go to the scanner no xray.
I don't think it was an error at all. In fact you would have had the scan done by the time xray got the pictures and developed them. It was pure time management.
Look at it even another way, you had to stabilize the patient to get them to the OR right? They could have crumped in the elevator on the way with no access to anything, instead because of your thinking he crumped surrounded by professionals instead of an orderly and a nurse in the elevator.
Every way I look at it you did the right thing.