Wednesday, November 19, 2008

"I Dressed The Wound, And God Healed Him"

First in an occasional series of my personal medical heroes.

Ambroise Pare practised in the 16th century; he came from a family with strong surgical connections: his brother was a Master Barber-Surgeon and his sister married one. He served on the House at the Hotel Dieu for a few years, but appears to have been too poor to pay the barber-surgeons union dues, and joined the Army.

Gunpowder had been deployed on the battlefields of Europe since the 14th Century, and had completely changed the pathology of wounds received there. The military surgeon, was, at that time, of a mind to treat gunpowder wounds in a way designed to destroy the 'poison' such wounds were thought to contain. The 'obvious' way to do this was through extensive cautery, or by pouring boiling oil into the wound.

Pare, however found himself forced to improvise; having run out of "oil of elders, mixed with a little theriac" (which was applied boiling t the wound), he was forced to use an alternative - "a digestive made of egg yolk, rose oil and turpentine"

On reviewing his patients early the next morning, he found those on whom the digestive had been used in an altogether better state, and resolved "never again to so cruelly burn the poor wounded by gunshot"

He also went on to describe the technique of ligating blood vessels in the context of amputation.

Friday, November 14, 2008

Highs And Lows

Back, at least for a while. I had intended to wait a day or two, to refit my life all at once; but this idea came to me, and I felt i ought to write it before I lost my mojo again.

I am become a creature of the twilight; lates and nights stalk my rota, and I've forgotten what a normal day looks like. I'm sitting among the detritus of my life that late shifts bring, drinking rum, if that helps.

Sometimes, I feel like we make a difference; sometimes I'm sure we don't. But I guess we try anyway.

The first comes early; or late, depending on which end you're starting from. The shift is a swap, and horror often seeks you out on a swap. Whatever Gods look down ensure that no good deed shall go unpunished. Actually, the shift had been fine. I'd been cloistered in Paeds and Minors all night, my most challenging case a complex nail bed injury; some poor fella's thumb transformed into an horror of pulp. I spend an indecent amount of time trying to put it back together before admitting defeat and sending him to see Plastics.

I look up, and it's seven in the morning. The department is pretty quiet, and I allow myself the thought that I might get away on time.

The phone rings, and the shrill tones gently nudge my adrenals. The sound of that ring is embedded in my cortex, somewhere, along with crash bleeps I have known, all of which still exert a Pavlovian pull on me.

Enough. The story is bad, telling a tale of a young patient hit by a van, not breathing. I have to push selfish thoughts, the knowledge that I'll be late away out of my mind.

We wait. The department seems to take a breath, and hold.... on.....

Then the Ambos arrive, and it's let out in a gasp. Our patient isn't breathing either, and not tubed - the crew are double tech, and no doc able to attend. We lift him over, and I see his colour for the first time, pale and waxy. It is the absence of colour, that in my experience means all his blood has left the building, so to speak. It is always a bad colour, and in trauma, and in the young, spells disaster.

He is not breathing, and we call for the Intensivist.

10 seconds later, it is worse; his heart is not beating. The ECG monitor glares at us, the flat line telling me what I already know. He's bled out, his heart empty.

Blunt trauma, cardiac arrest. Only his youth stands on his side; but I know it won't be enough.

I struggle, briefly, with the tube. Not long enough to make a difference to him, but enough to unsettle me; when the Intensivist arrives, i stumble over my words; this has gone runny really quickly, and I am, as ever lucky to work with a cool, efficient team.

I decompress both chests, to prove the lungs are up, hunting for blood, not finding any. We drill into his shins, cut into his groins, filling him full of blood cold from the fridge. His pelvis and thighs feel stable, and I still can't find his blood. We slide a needle into the thin sac around his heart, and tap 10 mls or so out. SonoSite tells me there's no more there, and that his belly is full of fluid, in this context, the blood I've been searching for.

I look around; an hour has passed, and we've replaced his volume, pumped his chest, pumped his lungs.

It has done no good.

We all know it. I ask for dissenting opinions, and there are none. We make eye contact, one last time, a gentle shake of the head. My day is done now, and I won't be able to see his family, to tell them how hard we worked, how hard we tried. I leave the department unable to meet anyone's gaze.

The next day; the same phone. An elderly patient, bellyache and low blood pressure. The ?aneurysm. During the day, the Department is that much busier, the waiting isn't the same. At night, you may become the focus for h whole department, everyone coming to help, or at least rubberneck. On a day like today, everyone has enough to be going on with, and the only breath holding is done by me.

He arrives, awake and groaning. We lift him gently over, and I see his colour for the first time, pale and waxy. At least he's still talking to me. The Ambos belt out the history, of an hypertensive, elderly patient, 2 day history of worsening abdominal pain, now going to his back and groin. They couldn't feel an aneurysm, but the history and the pale, sweaty patient in front of them meant they didn't need to.

I feel it right away. It's big; too big, I suspect for the Paramedic to have found it; but, to be fair, the Surgeon, who arrives within seconds, is also skeptical. The SonoSite, showing a seven cm mass convinces him. Big lines, a trickle of fluid and some morphine kit our fella up, and we run to theatre. I love theatres out of hours; long corridors, deserted, with odd trolleys stacked neatly, promising work to come. We deliver our patient, and I'm pleased to see how quickly everyone else gets going. Surgeons, Gasmen, Intensivists. I miss this life.

As we leave, I look at the clock. 30 minutes have passed since he hit the trolley downstairs. I don't know whether I should feel proud of this fact, but I do. My good mood is improved immeasurably when one of the nurses skids on a wet floor while trying to open the door to resus. I should add, she didn't fall, or hurt herself, but the effect was hilarious. After she's skated past me, I look at the floor of resus; I'm struck by how similar success and failure are in what they leave behind.

Before I leave, word comes down that he made it out the other side, and there's a little spring in my step as I leave.

Tuesday, November 11, 2008

Lest We Forget

In Flanders fields the poppies blow
Between the crosses, row on row,
That mark our place; and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.

We are the Dead.
Short days ago
We lived, felt dawn, saw sunset glow,
Loved and were loved, and now we lie
In Flanders fields.

Take up our quarrel with the foe:
To you from failing hands we throw
The torch; be yours to hold it high.
If ye break faith with us who die
We shall not sleep,though poppies grow
In Flanders fields.

Monday, November 03, 2008