Monday, June 30, 2008

The Gathering Dark

Some shifts you just want to go home and stand under a hot shower...

La Belle Fille has been away this weekend, living it up in the country. I have missed her, perhaps more than I expected. Which I actually think is a good sign, at least for our future. We seem well suited, despite the fact that what I intend as gentle teasing oft emerges as slightly insensitive / poor humour. My boss thinks she's to good fro me, and she might be right. Still, I am assured that she acquitted herself admirably both on guitar and vocals (in Rock Band.)

I am proud.

The Department was generally quiet today; but the BatPhone trilled its urgent call to shatter all that. Normally the figures Control relay to us are all business - pulse rate, blood pressure, Glasgow Coma Score... tonight, they added another - the patient's weight. 30 stone. (420 pounds, or 190 kilos) The raw details - respiratory arrest, found by his ex-wife; she'd been worried about him as he sounded off on the phone. His medical rap sheet made for grim reading. COPD, startlingly poor mobility; his house a veritable shrine to the machinery we gather to force the breath of life into us; deus ex machina if you will.

Too late, too late. Somehow the paramedics had managed to get a tube down, and his heart still struggled on. But he'd had no drugs, and showed no sign of wakening. As we tried to gently ease the news into his family's consciousness, he showed his hand. Harder and harder to bag him, higher and higher airway pressures. Pneumothorax - a collapsed lung - is always a possibility in these cases, and worse, because we were ventilating, the collapse progresses, air displacing heart and lung, literally squeezing his life out.

Needle decompression not feasible through such a massive chest wall, we set to thoracostomies. An elegant word for a bloody, violent procedure. They push the knife into my hand. It's a 15 blade, a tiny knife, a child's blade, but proves adequate to my task. Skin and fat offer no resistance, and my finger worms down to his ribs. I thought they'd be bigger, somehow, but they seem tiny inside his bear-like chest. The last push is blunt, brutal, with forceps. A gush of air greets my penetration of his pleura, the thin, greasy membrane that lines his chest cavity; the diagnosis is confirmed. Sweeping my finger between his ribs, his lung feels stiff, and is stuck to the chest. I feel a rent in the tissue of the lung, and a wave of nausea nearly overcomes me.

Have I slipped in too far? It shouldn't be possible, if the lung was fully collapsed, but maybe it has remained stuck to the chest wall in a few critical places? Maybe it is the lung itself that has yielded under my finger? My act is repeated across the chest from me, a distance that seems absurdly far. We place drains with shaking hands, and the water sealed drains bubble vigourously, angrily. Too much air, there must be an ongoing leak, and I know I've done something, something to add to his misery. If he could feel it.

He ventilates better for a while, then slackens off again. On my side, his chest is inflating, the soft tissues distending; under my fingers it feels like bubble wrap, and I know air is forcing its way into the fat under his skin, despite the angry bubbling of my drain. I check the holes - they're all inside the chest cavity, but still air leaks out elsewhere. Did I make two holes?

I've lost focus now. Fortunately, my colleagues have not, for our patient is circling the drain. I'm fixated by the drain. My mind is running overtime, replaying the act, searching, searching for the thing, the one thing that I might do, that I kid myself will make any difference; but I can't find it, and I know I've failed him.

My boss taps me on the shoulder, urging me to go and clean up. I look dumbly at my hands and arms. Somehow they're stained with blood; I don't remember it getting there; I clean up, scrub up, quickly. Things are moving apace now, and a crossroads rapidly approaching - one road leads to ITU... and one dose not. Wiser men and women than I will help him now. Another boss sees I'm running on empty, and ushers me out, to check the rest of the Department.

I turn, and walk slowly out of resus, my failure complete.

It is no surprise to learn later that he exceeded to limits of support we could offer him, and was finally allowed to complete his short journey. I hope someone was there to hold his hand, at the end.

La belle fille didn't ask about my day that evening, and I think I'm probably glad of that.

Sunday, June 29, 2008

Mea Culpa (2)

No dissection; and indeed I have the luxury of digital X-rays. An advantage that I did not use to it's fullest; indeed it seems slightly unfair to ask you all to comment, given the poor quality of the images... but it's only light hearted.

I was worried about the bases, and not entirely happy with the supine film, so repeated it, with patient sat up.

Here it is:
(I have tried to make the image bigger, but to little avail...)

The Missed X-Rays of Uncle Shroom

Part of the 'mea culpa' series. Hopefully, a very occasional series. In several parts.

Young woman, blunt force trauma to head and right chest. Primary survey unremarkable. Supine chest as follows. (Reported as normal by Radiology... and myself of course)


Thursday, June 26, 2008

On Top, Doggy And Normal

A Tale Of Three...

You came first; reluctant, disgruntled. A familiar ale, of a rough struggle in the night, steel toe-capped boots leaving their angry retort. A litany of complaints, of your head, your neck, your chest and your shakes. We saw you immediately. You argued with us then, unhappy at your confinement, unwilling to see the necessity... we explained, cajoled. You swore and threatened. We hoped it was your head injury... it was just you. We cleared your neck, offered pain relief, albeit not the opiates you wanted, eased your shakes. It wasn't enough. We were too slow to bring you the coffee and sandwiches you wanted. You told us you couldn't walk, couldn't see, couldn't turn your head. But when no food was forthcoming, you got up, looked around, offered one final charming epithet and walked out. In a straight line.

You came second; the pain you were told was gallstones finally peaking until you couldn't bear it no more. They found you on the floor, pale, clammy, groggy. Two minutes later, you were on our trolley; the scanner showing what we all knew was there, huge, obscene, spilling warm claret into your already swollen belly. 5 minutes later and the knifeman (actually a knifewoman in this case) is by your side. We've roughly violated every vein we can find, and the fluid has stopped the incessant drip of sweat, calmed your pulse to the low hundreds; you can think again, in time to absorb the dreadful news the surgeon carries; five minutes later, you're in theatre. I know you came through this most dreadful of ordeals, and maybe, in some way we helped. I'll look for you again today.

You came last; spinning off your bike in the lengthening darkness; the resentful ground bending you so cruelly to fit its purpose. We were on scene almost immediately, but it did no good. Cool plastic pushed air into your lungs, but the slowly cooling egress from the holes we made in your chest spoke of a darker outcome. The truth was starkly illuminated by our unforgiving fluorescents. The gaping rent in your thigh, as obscenely neat as any dissection I ever did, lay perfectly dry, an un-natural state in the living. An so we allowed you to pass on, eyeing each other with grim familiarity. A slow shake of the head, the turning away... all that's left is the meeting on the ledge.

Perhaps we all drove home a little slower tonight.

Saturday, June 21, 2008

I'm A Mr, Too

Belligerent Shroom; Brief post; Apologies.

Nights have been and gone, surprisingly quietly. The only evidence they were ever there are a few straightened ankles, and the disruption to my body clock.

One of Shroom's good friends has found her life goin' a little bit sour. Through no fault of her own, but because one of her housemates lacks social integration skills. I can't pretend to be in his head, and it's true that every story has two sides, but he seems to have a crush, for want of a better word, on her. And is having trouble adjusting to the fact that his feelings are not reciprocated.

I know how that feels, so feel I can offer the following advice: tough shit, Paddy.

Life is full of disappointment; how we deal with it is one of the ways in which we measure ourselves. There will always be things we can't have, people we think we love who don't love us back. And of course it hurts. Nothing is more frustrating than unrequited 'love'; I've been there more times than I care to remember - witness 'The Girl', who used the word 'horrified' to describe her thoughts on the matter; my feelings for her have been put into perspective by La Belle Fille - which makes me a very lucky Shroom.

But if you're not so lucky? Suck it up, buddy. Acting like an arse doesn't do much for your stock.

Words may have to be exchanged.

(On a lighter note, and to see if you're still reading: 3 words - Kung Fu Panda. Or is that 2....)

Thursday, June 19, 2008

Ionising Radiation

Nice to know that even eminent colleagues, like Dr Schwab, get odd visitors too.

A few pictures, I think. My night is slow, or was until I jinxed my self by writing that...

A personal triumph

The cast is perhaps not as well molded as it might have been, but I enjoyed the reduction.

An oddity:

Fell off the sofa apparently; was advised, over the phone, to ice it...

And lastly, a little sadness...

The images show CT of the brain, with the upper view showing a monstrous intra-parenchymal bleed - the white area inside the grey. An blood clot of truly epic proportions, within the very substance of the brain, and forcing its way into all the intimate nooks and crannies.

The coronal view was part of a CT arteriogram, so the bleed is less obvious, but is the ill defined light grey mass in the centre / centre right of the image.

The risks of anticoagulation; while we stop your cells clumping together, sometimes the fabric of a vessel just goes, and a claret spill of this magnitude is bad news for everyone. This came, as they invariably do, out of the blue, with no warning. Moaning about poor quality Saturday night telly one minute, flat out the next.

Welcome to DrShroom's Misery Bus.

He never woke up; they rarely do. NeuroSurg suggested that even if they could scoop it all out, there'd be no recovery. Risky surgery to end up locked inside yourself, not moving, not speaking... I'd rather not, myself.

If this wasn't sad enough, none of his family could be with him. The chance he might not see another dawn was a chance they, for whatever reason, were prepared to take...

Though I guess, in the final analysis, when it's our time, we all go alone. It's just a shame to see it.

Tuesday, June 17, 2008

The Singer Sings His Song

Another one down.

Did not exacly distinguish myself during my assessment today. Organisation evidently not my strongpoint. Something to learn from, I guess...

The Department was, surprisingly, quiet. We're one down tonight, so it'll undoubtedly be carnage. Most of my time was occupied trying to sooth the tortured mind of a young fella in the throes of mental collapse; for a while he did a good job of trying to scare us into thinking he was a 'terror suspect'. Paranoia strikes deep...

Is there hope for him? I'm not sure, but it does worry me that we started to see him in turns of what he looked like, what 'profile' he fitted, instead of what was wrong with him.

Or am I still too naive?

Monday, June 16, 2008

I'm Sorry?

In trying to post more frequently, while lacking the intellectual prowess to hold forth in a meaningful way about the big stories of the day, one runs the risk of running short of inspiration.

While casting about, I elected to see from whence my visitors come...

Most unusual referrer goes to whomever elected to use Google Australia to answer the query 'How is knee fucking done?'.

I have no idea why you'd wanna know, or indeed how they ended up here.

Food for thought? Nights await, so maybe some more laughs to share tomorrow.

Saturday, June 14, 2008

'There's A Weasel Chomping On His Privates'

Apparently, anything can be made funnier by the addition of the word 'weasel'. I'm told this is especially true if it can be shoe-horned into joke punchlines.

During the Annual Parade, Lt Col Smithers noticed some odd behaviour among the men of 1st Battalion. he asked his adjutant: 'What's wrong with Major Sharpe's men? They all seem to be jigging up and down as they march?'. 'Oh that', replied the aide, 'Well, apparently...'

The Cross Is In The Ballpark

There are very few moments in my job when I feel real fear; I see a lot of unpleasant things. I see a lot of sick people, and many of them make me anxious, because I'm always thinking the worst. But that's what I'm there for. Get on and treat.

But sometimes, something will happen that makes me pause, that sucks the breath right out of me. A time when you begin to think you might not have whistled loud enough on your way past the graveyard.

Perhaps this will clarify:

Last night began humourously enough; I forgot my scrubs, so borrowed a set from Sister. Dressed as I was in blue, everyone took the opportunity to look askance at me and call me 'Sister Shroom'. And it was honestly as funny the 20th time as it was the first.

Then, in one of the surreal moments that EM throws up, our reverie was broken by the arrival of an Ambo, breathless, clutching a small child in her arms. But come from the wrong direction. From the main Hospital, not the Ambulance bay. Such a simple thing confused me; I must have looked like the Village Idiot - slightly slack-jawed, as her words washed over us, in short, staccato bursts. Something about purple hands and feet.

Thankfully, the real Sisters had more presence, and we deployed to Resus. A beautiful little boy, small for his age, even smaller when marooned in the middle of the gaping trolley. He was gazing about, fixing us all with his eyes; he had beautiful blue eyes.

We all noticed that.

Dad gave an history of non-specific illness for a few days, topped off with lethargy today, and then the episode with purple hands and feet.

(As an aside, I'll simply ask you to regard your own hands and feet, and their colour. Unless you have circulatory issues, or are a grape fetishist, see how far removed the colour is from purple? Got it? Good. So you can imagine where purple is on Shroom's list of Colours I Am Glad My Baby Is Not)

He was cold, for sure, but he hadn't been in the cold. Rubbing his hands, I press his fingernail gently between my finger and thumb. It blanches, corpse white, and stays that way for far too long. We strip him off, compounding his indignity, adding to his childish outrage at life. His chest and belly are mottled. Warm bu mottled, and I can leave a ghostly fingerprint on his sternum for several seconds.

He's sick.

So shut down that I'm struggling for access; I call Paeds early, stammering over my presentation - the Model Professional. It always stings my pride a little to have to call them for help early, but it's not about me, and the kid doesn't care who draws his blood. In fact, I get a line in while I'm waiting for Paeds. Third time lucky? His hands are freezing, and I can see his veins, but they lie guttered beneath his skin, and I'm really running on hope. It's rare that I feel I really need a drip in someone, now, but I felt that way about him.

Anyway, Paeds arrives and we give her the lowdown again. She runs the ruler over the kid, establishing that his skin is not normally mottled (which I didn't even think to ask...)

And then it happens.

'And what about these petechiae?', she asks. 'How long has he had these?'

They Seek Him Here...

Christ. I really have been away for a few weeks. I, again, resolve to try to post more often, which, if you're still reading probably counts as good news.
For a certain value of 'good'.
And 'news'.

Anyway... one of my erstwhile readers, a proper doctor, not an honourary schmuck like me, has suggested a link between my real life and post frequency. He's more or less right. Sometimes, life just gets in the way.

So; an update. Non-clinical flail first.

Spent my time off NOT doing the hundred things I'd promised myself I would, so my car remains unserviced, and the kitchen unpainted. I did however spend some grand times in Wales, first with a bunch of citric types, then on a stag do.

Things I have learned include:
--It's not as easy as it seems to teach someone cannulation when your both blind drunk
-- It's not as easy as you think to find Welsh Lamb in Wales
--It's not as easy as you think to find Welsh People in Wales
--When you do find them, if you are a group of braying English boys in formal evening wear, they may not be quite as welcoming as you'd hoped
--My friend's definition of an 'easy mountain bike ride' is very far removed from my own...

Also managed some quality time with la belle fille. We exchanged parent's meets, which generally seemed to go ok. Although she's already told me her ma keeps her counsel about any perceived unsuitability until the offender is off the scene, so we'll see. Got into her da's good books by first, simultaneously, championing the GPs and belittling the Government (which is frankly all too easy these days...), then showing off my slightly geeky Dylan knowledge. (He's a Bobcat)

Charming my folks was easy for la belle; firstly she's charming and beautiful, so who wouldn't be? but also, I think they're just happy to see me with a woman. I suspect my Ma's granny clock is ticking, and my cousin's are siring offspring with almost unseemly haste...

Anyway, all seems well on this front, even as I test the limits of the embargo.

My friend survived his time on the Unit, and I embarrassed myself, just a little, in my effusive joy at seeing him again. I'm beginning to think there's such a thing as too much hugging; and another set of friends, citric again, have brought forth more of the next gen. All is good in the world.

Work has been... interesting. Our obsession with times continues, and has provoked at least one thing I never thought I'd see - management rolling their sleeves up and helping out. Pushing beds, no less. My annual assessment draws near, and as ever, my non-clinical portfolio is a bit anemic. We'll see.... I get to combine the 'hearing' with a string of nights, so stay tuned to see if I get to keep my job.