Monday, March 17, 2008

Everybody Wants It, Or Has It, Or Knows Where To Get It

More on time; I can't be sure of the quality of this post. I always mean to edit, but rarely do. There is an interesting picture tho'; I can promise that.

The medicine first; you can switch off thereafter.

Back on nights. Lovin' it. New guys, and gals, means more questions, all at once. Slower times. I set a new record. The entire board was full, 20 patients, ALL waiting to be seen. Awesome. Funnily enough, no-one was proud of me.

One of, if not my biggest, flaw, is my propensity to arrogance. I think I'm good at my job, and when it goes well, when the world falls into synch with my version of things, I get easily carried away. Sorry.

Anyway, I like nights. BBP was back on, and I thoroughly enjoy working with him. Not only is he good at his job, he's fun to work with, and gets some of my humour that otherwise falls very flat in the Department. Not all of it, and he might just be humouring me, but...

The picture:

One of many I have, that should not exist. Medics among you can probably guess.

The scenario:

A young man, stabbed in the chest. Single chest wound, left side, posterior, infrascapular. On scene, agitated, hypotensive, tachycardic, hypoxic. Scooped and run.

On arrival; distressed, pale - deathly white, you might say - waxy. Airway patent, spilling forth garbled words. Respirations ragged, fast, shallow. His left chest running a beat behind his right. Trachea midline, but the left chest quiet, oh so quiet. Normal percussion note.


But he's shocked...

Where else is he stabbed? X-Ray light the room up as I probe, urgently, hurriedly.

I can't find anything; X-Ray lights up the room again, telling me I can stop.

So: for the non-medics; this is a tension pneumothorax. The term pneumothorax literally means air in the chest. If there is air outwith the lung in the chest, the negative pressure in the lung will cause it to collapse. Simple pneumothorax. If air continues to leak into the chest cavity, with no route out, it becomes a tension. As the chest has a fixed volume, the air will eventually displace the other structures within the chest. This fella's heart is in the right side of his chest. (as opposed to left, e.g incorrect. In case you were wondering)

It's quite the opposite of where it should be; and it is this that is causing his blood pressure to be low, his pulse to be high, and my adrenals to be in overdrive.

It is a premorbid condition, and should be a clinical diagnosis - hence why the picture should not exist.. The path should be: diagnosis - treatment - life saved.

If it goes ?diagnosis - x ray - treatment, the next step is usually death.

As it was in this case:

(Not one of mine, and followed by successful resus, I hasten to add)

Treatment is simply letting the air find a way out. We put a tube into the chest, syphoning the air away, allowing the lung, literally, room to breathe. I want to teach an SHO to put the tube in; this will take time. So first, we decompress the chest. A large needle, mid chest, straight in. Compared to the tube we're going to put in, this needle is tiny.

In real terms, it's big enough. The patient, bugeyed, doomladen already, finds it hard to relax. Fentanyl to taste sorts this. In fact, he relaxes enough to 'fess up to having indulged in some stimulants.

The transformation post needle is remarkable. Pulse and blood pressure normalise. Always one for the melodrama, I clap SHO Spot on the back, and congratulate her on a life saved. The tube goes in next. Mostly smooth, but she has trouble getting her finger through the pleura. I don't have any tricks; my way needs a little more fent, but the track is made. I am briefly reminded of a Jean-Claude VanDamme film. (I think..? maybe Seagal?) The one in which protagonists harden their hands by plunging them into cauldrons of heated sand. I try to convince SHO Spot that this is why I can poke holes in chests with my little finger, and she cannot.

She almost believes it.

She wants to do Paeds, so I let her off.

As tube goes in, he springs his last surprise - a litre of claret runs down the tube. Hot, urgent, messy. I am struck by the contrast it makes to the claret we put in, which is cold, cautious and dark. The smell of the butcher's shop embraces us again.

Cardiothoracics breeze in, encouraged by the output from chest tube to take a peek. His very presence intimidates the bleeding, and the gush becomes a trickle. Nonetheless, he wins CT angiography. There is no ongoing loss, but I am slightly anxious to see my tube in intimate contact with the aorta...

He's doing well; a good day.

I go to tell his dad. His brother, also stabbed, wants to see him. I explain that the Police have asked, for forensic reasons, that the brothers be kept apart for now. I am amazed to see him actually square up to me. He toes the line, puts his face in mine and extends the view that he, the brother, cares for him, the patient, and what the Police say is of little consequence.

I offer a counterpoint that I, the doctor, have just saved his brother's life, so it is me that has done most of the caring, and the idea that he appears to be gearing up to fight me is slightly shameful. He is undeterred by this tour de force of logic, and I am (probably) only saved from a beating by his dad.

My favourite joke? (Totally unrelated, I assure you)

Q: What do you do on cocaine?

A: More cocaine.

The rest of the weekend was less exciting, but saw me win the 'Guess the sodium in befuddled old ladies' competition, and be called a hero by another patient. (For crawling under a table to get some sponge forceps)

Arrogant, remember.

We also mourned the passing of BBP's trauma shears. He was very upset, and despite us pretending to be shears, we couldn't find them. Mine disappeared the next night, in sympathy, but he was not an happy bunny.

My mouth has run dry. The non-medical jib will wait.

Happy St Patrick's Day tae ye all.



xxnemesis2010 said...

Hi Dr.Shroom!
I've been reading your blog for a while now and I really like your style of writing:D I want to be a doctor too someday.
Why is the title to this post 'Everybody Wants It, Or Has It, Or Knows Where To Get It'?


Baby Blue Pyjamas said...

I'm guessing its a lyric. Reffering to the intresting white columbian powder that was inside most of the patients i saw over the weekend.

DrShroom said...

Thx Nemesis.
The title is a lyric, or at least a paraphrasing of one from Lulu's Love loves to Love.
Sometimes the title bears reference to the post, mostly just cos I like the lyric.



the little medic said...

Interesting post!

I've not seen anything quite that acute or interesting in A&E so far although I have been having lots of fun suturing heads etc etc.

Mousie said...

Love it!

Great post.

Mousie :o)

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Baby Blue Pyjamas said...

I showed my dad your tension pnumothorax. he was very impressed that you fixed the patient.

Alice said...

Also, has this man swallowed two big luggage tags?