Tuesday, July 22, 2008

On Responsibility

Talking to the mother of one of our patients today was hard work. She was on the end of the phone, in a tropical hideaway. Her relative was with us for the second time in three days, brought by family friends.

The first visit followed a fit, but we knew they had epilepsy, and there was nothing unusual in this. Even if it was, as she put it, 'a big fit'.

Today was for an overdose. We ran the medical ruler over the patient. All clear, no ill effects, the recommended observation period passing with incident. The headshrinkers came down and opined. No need for sectioning, no need for admission. Community support in place.

The phone call was hard work because, after all this, I proposed to discharge the patient. It was half five in the after noon. 'So you're just going to put them out in the street?' she spluttered; I allowed that, while that's not exactly how I would phrase it, we were going to discharge the patient.

'But getting home means taking buses, and trains...'

The patient was well over the age of 21, living independently, and had been taking public transport, unaccompanied, for some years.

I just know there'll be trouble from this, but I'm not sure where they think their parental responsibility ends, and mine, as Emergency Physician, ends. I think what they wanted was the patient detained, possibly encased in cotton wool. The outrage, that we would not admit them for either their chronic, stable medical condition, or for the psychological flair up, or indeed because the patient's keys were at a friend's house, was palpable.

On Pathology

Students in the department today. This usually means it's very quiet, but not today. Chief among the citizens who walked right out of a textbook was a fella who had been rather too friendly with the booze; years of one too many had rotted his liver, shrivelling it and firming it up, making it almost impassible for its rich blood supply. So now blood finds another way round, and one of those ways is through large dilated veins at the base of his oesophagus.

When these varices leak, they do so like a hose. He's been through this once before, but been lost to follow up. So he sat before us, shivering, an odd lemon yellow tint to his gaunt skin. Even as we called the Magicians and the endoscopist, telling them that he was stable, we knew it would turn out to be a lie.

But he didn't look too bad.

'Fooled you'

Innocently mumbling something about feeling a bit rough, he sat up and disgorged a river of claret. Bowl after bowl he filled, till his pressure dropped low enough that he couldn't hold his head up no more.

And still it came.

Then we moved in a blur. Organised flail - central lines, arterial lines, blood, platelets, the works. Curiously, he was most worried about having to have a catheter, and fretted about the speck of vomitus that streaked his chest, daubing him like some sort of Biblical door-frame. Odd, what seems important when one's life is literally draining away.

As all this raged, a young fella stabbed to the chest occupied my colleague on nights, and as I left, I saw the Sister of the Night pass him a CodeBlue sheet. I didn't catch the full story, but distinctly heard the words septic and unwell.

When it rains, it rains...

On Flail...

Grand old weekend with La Belle Fille... mild deployment of crossface. I think the honeymoon period is over, and we grump at each other a little more. This is probably a good thing; stops the evil humours building up.

And then... after driving to Kent for a toddler's birthday party, with balloons an' all, then back to La Belle Fille's place, my concentration wavered for a mo'... and wang!
Clipped the curb at 60, and shredded the offside near tyre. Didn't roll it, flip it or get rear-ended which is to be thankful for, I guess.

Swore a lot, the called the AA. Their rep took an hour and a half to find me, and when he did arrive, gave me an earful for not knowing where I was.


He recovered me to the nearest services, before gleefully telling me I'd fucked the wheels good and proper, and would not be going anywhere that evening. He then told me the AA wouldn't recover me, as my 'breakdown' was an RTC.


Reaching into my oversized wallet, I found my insurance details... missing. A panicked phone call to the Belle Fille, and she was able to surf the Web to the number I needed. My affection for her knows no bounds.

Insurance company eventually arranged for me and the car to be recovered. The following morning, the fattest Oriental man I have ever seen handed over a courtesy car, but kindly refrained from sucking his teeth at the state of the Shroom-mobile. I still wait to hear, and the Insurance will cover it, unless I've secretly written it off.

Details to follow as news warrants...

Thursday, July 17, 2008

If I Should Fall To Rise No More...

Another one of us runs aground; a fellow blogger, whose work I try to follow closely has been rumbled. It's always a risk, if one tries to keep this sort of thing secret. For those of us who blog about events that might have involved other people have to worry about libel, and, for the medical blogger, issues of confidentiality.

There have been a few relatively high profile cases, and I think it's why most, if not all of us write hypothetical, or composite cases. I occasionally mention real people, and talk about patients, but I remind you all once again that the details of the cases are representative only.

Except of course when I saw that Patricia Hewitt is a bitch. That's true.


Anyway, I'm not sure what fate awaits our fellow blogger. People I work with know I blog, but have chosen not to take me to task over it; I'm fairly sure my writing is cast iron enough. I guess it's probably good advice not to describe colleagues in a derogatory way unless you don't care if they read it.

Which brings me nicely onto another rant about my surgical colleagues. I apologise for the overly whiny nature of my recent posts. But I need to vent. Colossus, God love him, had to endure my initial autologous autosplenectomy on my way out this eve. Now I choose to share it with y'all. I'm trying to vent enough that I won't chew La Belle Fille's ear off.

In defence of my colleagues, I'm sure they are all excellent surgeons; and, I have no doubt, that if you quizzed them about me, there would be plenty with which they could find fault. It is easy to paint a picture that seems to make your point of view the reasonable one. What follows is thus not an objective telling.

It's my blog, however.

Again, this morning, the facial surgeon was confronted with a patient with diabetes. The mere presence of this rare and exotic condition seems to have struck fear into their hearts, and they duly requested a medical review. When they were directed in the direction of the phone, and provided with the bleep number, the better to discuss the case themselves, it was decided that, perhaps, discussion with the duty magicians was not necessary, but would the nurses ask me to look over the results.

When I was a wee fungus, we always directed our questions up the chain before going sideways. I'm not sure when that stopped.

The patient managed to give their own insulin, as they do every day, without sustaining horrific mishap, and got to outpatients in one piece.

This afternoon, I spent a joyous time talking on the phone to several of my colleagues; my conundrum concerned a young woman, obviously shocked, with obviously intra-abdominal mischief. The cause was not immediate apparent, but we were leaning toward an abdominal aneurysm. The General Surgeon was sure it was an aneurysm, and wanted a scan. He was reluctant to see, or touch the patient. The Vascular Surgeon was equally sure it was not an aneurysm, and wanted a scan. He was equally reluctant to see, or touch the patient. I eventually managed to get them together, but this did nothing to disabuse me of the idea I have that we are increasingly substituting 'a scan' for examination of the patient.

Interestingly, despite all the assurances to the contrary I received from the Vascular boys that an aneurysm was not the problem, the scan suggested otherwise. I saw the vascular boys after the scan; no comment passed between us about how interesting the results of the scan were; I suppose they were rushing too quickly to theatre to talk.

Lastly, and what eventually kept me at work two hours after I should have left, I spent some considerable time with a young patient. They have a complex psychological disorder, which results in frequent visits to the ED. Much time has been devoted to the investigation of their symptoms, and they frequently take their own discharge. Tonight was no exception, but what nearly pushed me over the edge was when the patient was returned, against their will, by two well meaning non-clinical staff. Despite my best efforts, I surely felt that they considered me derelict in my duty, as our patient did not look well. The idea of capacity, and right to refuse treatment did not seem to compute. We eventually parted company, agreeing to differ, as my well meaning colleagues were not willing to wrestle to patient into the Department, not willing to section someone they know nothing about. Which is just as well, since merely behaving in a way you don't approve of is not grounds for declaring someone mentally incompetent.

I suspect I may hear more about this one.

I'll try to be less sanctimonious tomorrow; I'm sure it doesn't become me...

Wednesday, July 16, 2008

Singing The Body Electric

Hacked off.

Lethargic, a bit febrile, and with, as ever too much to do, and too little motivation.

Spent the weekend with La Belle Fille, but was so intent on trying to make her proud of me in front of her friends, rather became a show off, and then something of a penis. Just once, it would be nice if I could cut loose without being an arse; mea culpa, mea culpa, mea maxima culpa.

Have found sleep hard to come by the last few days, so increasingly ratty at work. I always resent being tired ad grumpy at work; it makes me short with people who don't deserve it, or at times when more could be achieved with less acid on the tongue. Particularly frustrating to me today were the efforts of some of my surgical colleagues to avoid admitting an old boy with a dental abscess.

I fully recognise that I am, at times, less than the most conscientious doc, but I always try to do my job. I do not turn away from what is difficult, because it is so.

So, when confronted with a patient labouring under the ravages of a dental abscess, it would be nice if this was greeted with pleasure; not at the illness, but at the opportunity to make someone better.

Not with excuses, and lame promises to treat the patient "as an outpatient", while at the same time suggesting admission under an alternative team. To say that, as a doctor, you do not know how to treat someone who is confused, should really be too embarrassing to contemplate. Instead it seems to be a valid reason for not treating the patient.

I find this increasingly among the surgical specialities, who seem set on returning to the days when they were not Doctors, but tradesmen. One of my orthopaedic colleagues, when referred a patient who had, with a sharp knife, opened her wrist into the joint itself, declined to take on the patient because she had also taken an overdose, That the OD was non-lethal, and over 12 hours old meant nothing to him. He was genuinely afraid that the patient might become unwell in a way that was beyond his ability; and was quite prepared to neglect treatment of her semi-severed wrist to avoid such a possibility.

I sometimes wonder if we all really did go to medical school...

Sunday, July 06, 2008


Wimbledon is going to the wire as I write...

So - yes, a fractured clavicle, which was spotted; but as the second recall X-Ray shows, a few busted ribs too. Try as I might, I cannot see them on the original, even with the advantage of digital viewing, denied you guys...

It's still not a brilliant image, but I think you can see the healing right sided rib injuries. Thankfully, no underlying lung damage.

Nights pass, as they do; Friday was busy for TooTall Student, so I think she got a good flavour of the ED. My main flail was trying not to call her by La Belle Fille's name... We ended on a Shroom 8 a.m. special. Just as we wound down for handover, the call came in, courtesy of BatPhone. The real deal - 40s, cardiac arrest 15 minutes away. !5 anxious minutes to try and gear up, try and get your mind running again. The nurses change at half seven, so they're fresh, but we medics all smell a little fusty. It's an odd scenario, as the bustle in resus goes on with the night guys drifting out, saying their goodbyes, making breakfast plans...

As our patient arrives, so do the day staff; we're short handed at weekends, so I stay and DayReg takes handover; he floats on the periphery, filling in the little details that my morning brain can't quite fix on.

The damage - a young fella, we think he has Wolff-Parkinson-White, an electrical short-circuiting of the heart, predisposing him to arrhythmia; we think he may have taken some drugs... we know he was found down at 7, we know he had no output at quarter past. He is unceremoniously dumped on our trolley, the Ambos herding round, bright-eyed, a sheen of sweat on a few brows; they've done their bit, and done it well. They know this, and don't need me to tell 'em, but want to know if we can finish what they started.

Chaos ensues, for a minute or two, checking the tube, forcing air into unwilling lungs, hands slipping on his greying chest. Then, we pause, come up for air, re-assess.

Got him.

Weak, yes; thready, yes. Hardly a thing to be proud of, but he's got a pulse. His rhythm is crazy on the monitor, never staying in one place long enough to get a fix. More drugs, more air. ITU and Cardio arrive.

Lost him. Four more frantic minutes until we find him again, pull him back over the edge. ECG shows a large MI, and we know why; the CathLab is being warmed up - we have indeed moved into the 20th Century - but I'm not sure we'll get him there.

Thankfully ITUMan is. He doesn't strike the epitome of cool across the room, but he is. Collected, organised, he casually takes over... and I am glad. Slowly, the patient heaves to, listing a little, for sure, but slowly doing what we want him too. ITUMan disabuses me of some ideas about the properties of fentanyl, and I feel generally clumsy next to him. I blame my 8 a.m. brain.

No matter; just under an hour later, he rolls out, with our patient, stable for now, onward to the CathLab. From what is undoubtedly at least two people's public tragedy, we are all smiling. We've done well, here today. Done what we were paid to do. We don't know if it will make any difference in the long run, but that's not our job. A little messy, disorganised? Probably; I expect I shouted a bit too much, too, but he came in dead, and went out alive... cliched?

Sure, but right now, I don't really care.

They're still on at Wimbledon...

Friday, July 04, 2008

The White Hare

Another long week... nights to follow; I swapped a while back, without realisation that this would lead to a 14 day stretch... I suppose our sins always find us out, and it could be worse...

Too-Tall medical student is on with me tonight, and has promised not wear heels, so maybe I can play some part in furthering the education of the next generation. Or not...

Many brave small folks this week. I think I've offered before on how the self-possession of some children just takes my breath away. I don't know whether his is because they've been brought up that way, or if they just are.
This li'l fella let us straighten this with just nitrous; he barely blinked...
Go figure...
Well, time to see what joy the night will bring. UK readers should take the time to go see Kung Fu Panda. You know it makes sense.

Dance Like Nobody Is Watching

ImpactED nurse is always worth reading; but occasionally unearths a real gem. There's hope for us all...

Mea Maxima Culpa

Continuing the missed X-Ray series.

I thought the second radiograph was o.k; so I fell back on the age old staple of serial observation. The patient settled, so no CT. 3 weeks later she called to say the pain had not settled, and returned for a review...

I apologise for the limited quality of the images thusfar; but I think the abnormalities are visible on this one; sadly my colleague, who reviewed the patient, didn't...