Tuesday, April 21, 2009

Nights Part Two

In retrospect.

They were pretty decent actually; low volume, but occasionally complicated patients. Working with one of the Charge Nurses who spent the evening cheering himself in an understated manner... this is difficult to convey with the written word, but try to imagine an ironic cheer: a sort of sarcastic, sotto voce 'hurrah'... but for yourself.

Well I thought it was funny.

Maybe you had to be there.

Satisfaction came, as it so often does, in the form of two sickies. The first, in the late afternoon of life, with chest pain and an ECG that told all we needed to know, its ST segments sagging painfully in the anterior leads, dragging themselves up inferiorly. He was holding it together, just barely, his skin a grey sheen, his breathing ragged, and forced. I called Cardiology down, again, pushing more work their way. We're getting good at this shit now, buffing and polishing, prepping and turfing.

I take pride in being the ED Reg other registrars don't want to work with, the one who brings them work. (Not because they think I smell, I hope...)

The patient, in these situations, finds themselves immersed in vocal turbulence; the chat flows over them, sometimes turning to glance at them; rapid explanations duel with checklists being checked, bloods being drawn, phone calls being made. Mostly it's too much for them, they drift in ad out, an island in the middle of the rush to the balloon.

This one faded out a little too much; he just leaned back and ...stopped. The monitor quieted its annoying, monotonous beeping, and the display moved from regular, friendly complexes to an ugly mess; jagged, irregular lines. Cardiac rhythm by Picasso on acid.


A brief, very brief pause stretches out before us, as we all see it at the same time. These moments feel like stretching toffee... everything seems to slow down until they... snap, and we're back in the room, and it kicks off.

Praecordial thump, more in hope than anything does nothing, and the bed clatters down, damning any fingers too slow to get out. Sweaty hands begin forcing his chest down, one...two...three... to the tune of Nelly The Elephant, and the pads come out, electricity arcs through his chest cavity, and finds its mark. The monitor coughs, and splutters; when it recovers itself, the rhythm has normalised, and the patient's arms rise, rise ever so slowly, but rise to push us away.

Another of those elastic pauses... then **snap** he's back in the room, and the machine begins to turn again. Minutes later, the whirlwind has gone, blowing out of resus, leaving behind scattered syringe wrappers, dental rolls and ECG dots. ThromboNurse brings us his angio later, and we see his obtuse marginal artery, dammed with clag before, flowing freely after, and he's doing well.

A sotto voce hurrah doesn't quite echo through the Department.

The last, probably the worst. A young 'un, barely past the dawning of his day. Mum knows he's unwell, he's been off colour since last night but this morning has found his rash, and brought him to us.

I know he's not well; as they're ushered in, his skin is pale, sallow, with dark ugly circles under his eyes. His sits on Mum's lap, withdrawn, huddling into himself, but still bright enough to look about him. The history is quick to come out, and in between questions I'm asking staff to get me the tools of this particular trade: a cannula, blood bottles, fluid, antibiotics... we need his weight, but he's too weak to stand on the scales. I ask if mum will weigh herslef, then the two together, and she hesitates. I find this slightly absurd, in context, that her son is sick, and still she's worried about us seeing her weight.

I dismiss this as unworthy, she's terrified, she's not thinking straight, and we weigh him with me, instead. The cannula slides in, and he barely flinches. We've all seen the wretched rash by now, obscene reddish-purple blotches under his skin, the only colour left in him by now, and one none of us want.

Fluids and antibiotics follow the line in, and Paeds are down in a flash. My SHOs have watched in silence, not having seen this before, but recognising the gravity of the situation. We talk in hushed whispers afterwards, and I hope this means they never miss a sick kid, that this will serve to be their reference.

I leave him with the Paeds Intensivists, their presence both reassuring, and a stark reminder of how this disease is likely to pan out.

Calling PICU that night was hard to do, I'm not sure I want to hear the news, but he rallied they tell me, is well enough to be bored; he dodged to tube and hasn't needed inotropes. Mum brought him to us soon enough, and he's tough.

The 'hurrah' is a little less sotto voce

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