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...