Wednesday, August 13, 2008

Hard Done By

Self deprecating... maybe; it's almost a requirement of the Citizenship exam these days. "Hard-done-by"..? Not really, and we all know it... but it does make for better copy.

For most of you, this will make precious little sense... but you know who you are.

Sometimes you see people get sicker before your eyes. I know that sounds somewhere between common sense and bollocks, but it fits, if you think about it. I've blogged about it before, but can't quite remember when; no bother. What I bring to the table tonight is the opposite. Which is always better. Almost by default, we of God's Children in the ED tend to assume the worst, and work backwards. You miss less that way. And when BatPhone goes, you prepare for the worst.

For example: the call comes in, warning of an adult male, stabed in the leg, in the thigh. Pale sweaty, tachycardic. The thought that flickers in to view, that crawls out of the back of the subconscious is the Butcher's Cut. Well, that's what Pa Shroom called it. KnifeMan slang for the wound that cuts BigRed, BigBlue and BigRed again. One cut, in the groin; the unkindest cut, the Butcher's knife slipping past the apron...

Plenty of claret, difficult to stem.

So you prepare for it, steel yourself and in rolls a very healthy looking fella with a wee knife in the front of his thigh, minimal bleeding. And he's waving. A jaunty smile, God love 'im. He has the decency to look slightly embarrassed, but by now, you don't care, because the patient just got better in front of your very eyes.

Last night: the call is worse. A young 'un, a tweenager, found down, unresponsive, no blood pressure... no more details, but what you have is bad enough. Late at night, it's just you; you hurry to guess-timate their weight, prepare the drugs you hope you won't need, gather your wits.

The Ambos roll up, and already its better. They're older, more responsive and obs sit on the normal. You take a breath, but still have a vomiting comatose teenager to deal with; this is still not an happy combo. They have definitely NOT been drinking you hear as you offload onto the trolley. They heave, determinedly, and you do the gallant thing, and roll them onto their side, but ensuring it's the side that faces Sister.

In the vomitus? Vodka. Sister has a nose for it. I can't smell it, but she assures me it's there. I learned early not to doubt Sister.

So, in about 30 seconds, my patient has transformed, from one with no blood pressure, and no neurological function, to one who just had a bit too much fun.

Now, granted, people still die from drinking too much, but rarely, and here is something we can deal with, something significantly more benign. Drunk teenagers? It's virtually our speciality...

The same patient provides us with the best quote of the year a little later. Sister, while assessing our patient's response to pain, employs a technique not unlike Mr Spock's Vulcan nerve grip. As well as confirming our ability to wake this patient from the alcohol induced slumber she presented with, it elicits a response that draws heavily on an epithet that might derive from instructions to procreate issued by a monarch.*

Sister is not keen on bad language. "Don't say that!", she implores. "Couldn't you say something else? Something like: 'Oh, Fairies!'"

*Fornication Under Command of the King since you were wondering....

Sunday, August 10, 2008

It is three in the morning, and all is not well; I have had to recuse myself from the floor, after suffering a compassion breakdown. (I hope I’ve used the word recuse in vaguely the right way, as I’m only doing so to try and impress my legal readers; well, one in particular… ;)) Today is changeover day, so all the characters in our ED drama have changed; I wonder if the punters of our catchment area know this, but suspect coincidence.

On the good news front, La Belle File is back; in fact when I was finally able to re-establish voice comms, her first words were: ‘I’m back!’ delivered with some conviction. I’ve been on nights, so joyous re-union has been slightly muted. Work, however continues to provide cortisol raising frustration;

The complaint
Complaints piss me off. I should say that I am in favour of them – people must be able to challenge our decisions and our authority if they feel we have wronged them; and we must be transparent in our practice, and robust in our defence, even of controversial or unpopular decisions. But people who complain when they are ill informed, or who will not let something drop… it is these guys that hack me off. I am currently answering for my actions of a few months ago, largely because someone not connected to the case is trying to dodge the real issue. Clearly I cannot go into detail, but a situation arose in which we had to deal with a particularly difficult patient, and were required to make several decisions for this patient, and implement them against the patients wishes. Further assessment required specialist practitioners, who were duly called and advised the patient be removed to a place of safety; some force was required to do this, and the patients relatives were unable to see the patient for some time thereafter. They clearly felt excessive force had been used, and that the law surrounding management of this kind of patient is archaic.

They have a point.

They wrote to their local representative asking what might be done to bring about reform of the laws governing this sort of situation. Their letter barely mentions the hospital, and is not critical of our treatment. Yet this representative, who I suspect spends more time polishing green leather sofas with her ass than knowing her job, has written to enquire why the patient were not more closely supervised, and why transfer to another facility not enacted earlier. The patient in question was given one-one care at all times; they could not have been more closely supervised; and the transfer did not take place because the other facility did not want the patient, not in the state in which they ran amok in my department. And yet a casual question implies poor practice on our part; and does nothing to address the original question, of what could be done to make the law more palatable.

In truth, part of the problem lies in that there is no gentle way of subduing large, violent aggressive patients, and their restraint will invariably leave them shaken; laws will not change this. Some people cannot be talked down, but relatives will always feel for their own; there is, of course no mention in any complaint of the physical violence visited on us by the patient…

The poor wee fella found at the bottom of the stairs by BBP has had insult heaped onto injury. Any death with 24 hours of admission must be referred to the coroner, and the circumstances of this case mandate an inquiry. Because the patient still lived when I went off shift, I could not contact the coroner, and neither the doc who certified, nor the admitting physician, nor the neurosurgeon who would offer no hope nor the intensivist who passed and pulled the tube would spend 10 minutes on the phone to the coroner to tell him this. An huge round of shoulder shrugging, not my problem, don’t wanna get involved. All that was required was to phone the coroner’s office, and tell them the sad circumstances. I did it; it can’t be that hard, but their indifference has left a family in limbo for a further six days, until I came back on shift.

As for tonight, and my recusal

I generally try to be empathic, and compassionate to everyone; but as I started this piece, the only patients inn the department were as follows:
Hypoglycaemia – known diabetic, brought on by not eating, and drinking 12 cans lager
Drunk, slightly hysterical following argument with friends (not present in dept)
Drunk, decided to go swimming. Got cold, may have fainted
Drunk, mixed (non-lethal) OD
Not one among ‘em with a proper problem not self inflicted. One ended up punching a staff member, and left with HM constabulary. The rest enjoyed a restful, warm night at the taxpayer’s expense.

The last two nights have been a bit psych, in that we’ve mostly ended up chasing semi naked girls about the dept as they scream at us. One, declared fit for d/c, escaped and was found in a bush, shivering against the thin covering afforded by arseless hospital gowns, with her thong tied around her neck.
Our psych cover seems woefully inadequate. The liason service soldier on, but their primary mission was never intended to be the MH assessment of all and sundry in the ED; and yet we have nowhere else to turn. Why the psych SHO cannot do an on call like every other bugger is beyond me. And woe betide you if you’re over 65. They do have an on call doc, but they don’t get out of bed; at least not to come to the ED

If you have severe aortic valve disease, and undergo surgery to have it replaced, basal atelectesis post op is not unusual; nor is it unheard of for LRTI to develop; but when you return, 12 days later, with that LRTI inadequately treated, and worsening chest pain, breathlessness etc, it seems that your problems no longer concern your surgeon. Post op complications would appear to be either a thing of the past, or something the surgeons are only to keen to farm out to others. If our knifemen are only going to be just that - knifemen, technicians, hernia specialists - then why the fuck should we pay to send them through medical school..?

**Rant ends

Sunday, August 03, 2008

On Politics

It's mostly bollocks, let's be honest.

La Belle Fille has been away, I have been moping. Drank far too much yesterday, celebrating a friend's impending wedding; have to work today, which obviously I am very pleased about...

Was paid a sort of backhanded compliment by a neurosurgeon the other day, when they opined that I broke bad news well. I suppose if you're going to ruin a family's day, you should do it well, but I can't help but feel it's a sad thing to be good at.