It's Not Rocket Science

So...


Stabbed in the face, eh?


The blade entered, externally, just below the right eye, and appeared to be directed superomedially, that is upward and toward the midline. As best as we could tell, the right eye was functionally intact.


What happened next is both instructive as a comparison to what we might have liked to have happen, and, it should be remembered, coloured by being fired through the prism of my memory.



If that last don't make sense, what I'm getting at is that memory is very plastic. Two people seeing the exact same thing often have very different memories of what it was, more so when they are both interacting with whatever it is; and of course, there is sometimes considerable change in even a single individual's recall.




So, maybe this isn't how it happened; but it's how I remember it happening...




It seemed obvious to us that MaxilloFacial needed to know about this guy; the radiograph from before was taken in something of a hurry, hence the monitoring lead in situ; it's not ideal, but it seems churlish to moan. It's not really in the way...



My first thought, on seeing the film, was indeed: 'Ooo look. That looks an awful lot like the blade is in his brain'. I shouldn't have to tell you that that scores fairly highly on the ShroomScale of places you'd rather a knife was not. My MF colleague was less convinced, making the (entirely valid) point that a single view doesn't give all the info you need. So, what you're getting is a 2D view of a 3D structure; fair point. It still looks like it's in his brain, mind.


The situation got slightly distracted while a discussion ensued between MF and Ortho as to who should take the patient...


(MF: 'I think he's got a head injury... that's Ortho'
Ortho: 'I'd say the knife in his face is probably the most pressing injury...')


Meanwhile, his GCS was slowly, ever so slowly slipping downward. Fortunately the Charge Nurse was a little more focussed and brought this to our attention. MF seemed less concerned by this - 'He is drunk, after all.... maybe you guys can just watch him here for a bit..?'



Maybe.




My arse.




If you have a knife in your face, that might be sticking into your brain, if you might have a blunt head injury on top of that, and if you are becoming less and less awake...


Observation is probably not the way to go.

Put Down Your Guns Of Steel

I think I've said this before, but when the BatPhone rings, the info we get is sometimes ambiguous; it might be something, or it might be nothing.

Stabbings are a good example of this. The history 'stabbed in the ....' doesn't tell you much, in and of itself. Stabbed in the leg could mean the butcher's cut, hacking through all the important clockwork up near the femoral triangle, or it can be a loon who's poked a knife into their quads, and is quite enjoying all the attention. (I've seen both...)

'Stabbed in the face' feels more visceral, more serious. Maybe because there's not so much soft tissue that's safe to stab; 'slashed across the face' might look more gory, but, somehow doesn't convey quite the same feel to me.

That having said, if you've been stabbed in the face, there are a variety of 'safe' places the blade could go, all of which are going to ruin your day, and your movie star looks, but none of which will ruin everyone else's day.

There are, of course, an equally large number of places that blade can slide which will change your whole outlook on life. Phineas Gage demonstrated that rather admirably, albeit unintentionally. The whole 'science' of lobotomy / leucotomy was based on this.

So, the warning call of 'stabbed in the face' is alive with promise, with danger, with fear and uncertainty; only when they roll in do you know.

When this guy rolled in, the question of how serious it might be looked rather foolish. He was alive (good), conscious (good), with no obvious bleeding (good), but obviously shitfaced (bad) and with about 2 inches of metal poking out of his right cheek (very bad)

I'm guessing you can see the problem... the horizontal line is a monitoring lead, the (roughly) vertical line is all knife.

I Am The Muffin Man...

Regarding my thought experiment:

For the purposes of the experiment, I was talking about real muffins, such as one might buy from any shop.

And I should re-iterate that this is purely hypothetical. After all, no-one would ever use the Ambulance service to convey muffins, would they?

Sad Will Be The Day

Occasionally, a Doc attracts a particular breed of patient.

I used to be that Doc, and must confess to being slightly glad I can now pull rank, and let some of my junior colleagues deal with the inebriates who think it the height of culture to try and wave their whangers in your general direction.

This weekend had a fair few of these guys, and most of them ended up being seen by one junior. She then topped them all by treating a guy who was concerned that he found a spider in his Pot Noodle; Well, not so much a spider as... half a spider.

We await the news that PotNoodleGuy has developed super powers, and started scaling walls for fun.

If You Should Chance To Meet Me...

Sorry, I've been away too long; I see some of you still checking in regular, like, and I have a feeling others get updates thru' the mastery of the Interweb wot I don't really understand.

I am always curious to see how people get here, and somewhat disappointed that it's mainly from other blogs, or by direct url. AlrightTit has an host of humourous keywords leading people to land on her blog. If you aren't among them, you should be.

Go, now, and seek her out from my sidebar.

But be sure and come back.

So far, some poor bugger has landed up here after searching for "Tom Jerry hose burst / swell"; I'm fairly sure this slightly bitter rant is not what he was hoping for, as there can't be said to be a great deal of similarity between these words and the light-hearted comedy of the infamous cat/mouse double act.

Still; with the aim of providing a little light entertainment, I'd like you to participate in a thought experiment.

Clear your mind, and imagine the following:

Suppose a patient came to the ED. He has, let's say, for arguments sake, been apprehended in the act of reckless driving. He might even have been drunk; he might have stolen the car; he might have crashed into another vehicle and tried to escape on foot.

Having failed, and injured himself in the process, let's say he behaved in a generally unpleasant way to all the Health Care Professionals concerned in trying to effect his treatment. Threatening the Ambos, swearing, generally acting the arse. That sort of thing.

Now imagine he gets a clean bill of health, and is carted off by her Majesty's Constabulary... until the next day, when he has a seizure. Plod calls the Ambos' who, let's say, do their best to reassure all and sundry. The (imaginary) patient, it transpires, is epileptic, and been off his meds a while. He's not post ictal at all. But suppose his solicitor is keen for this fella to be seen at Hospital again. And imagine its the same crew he so roundly abused. They might not be pleased to see him.

They might also not be so pleased if his solicitor were to ask them to convey the patient's muffins to hospital;

---------'As you're going anyway chaps, I wonder if you'd bring his muffins. He does so love his muffins. Yes, I'm terribly worried about a potential head injury, but don't forget the muffins.'

Imagine the patient is no more pleasant than he was the day before.

What do you think might happen to his muffins?

Anyone?

When you have multiple injuries, a multi-disciplinary approach is required; what this seems to mean at my place of work is that all the relevant specialists offer to 'fix their bit' as long as the patient is under someone else's care.

So: when your injuries are:
Minor head injury - no skull fracture, no bleed, no brain injury
Facial contusions - no fractures
No spinal fractures
Laryngeal cartilage fracture, undisplaced, no active intervention required
Subconjunctival haemorrhage, normal visual acuity
Multiple rib fractures, with right pneumothorax, requiring tube thoracostomy
Ruptured oesophagus - at about mid thoracic level
No abdominal, pelvic or long bone injury

Who should be the Speciality in 'overall charge'?

Who should admit the patient?

Maxillo-Facial?
Ophthalmology?
Ear, Nose, Throat?
General Surgery?
CardioThoracic?

Answers as usual, please... I think they're still arguing about it at work

In Celebration...

Of The Bleedin' Obvious

"I have never, after gastroenteritis, said: 'that was awesome'"

Bad Times

Stop all the clocks, cut off the telephone

Prevent the dog from barking with a juicy bone

Silence the pianos and with a muffled drum

Bring out the coffin, let the mourners come

Let aeroplanes circle moaning overhead

Scribbling on the sky the message: He Is Dead

Put crêpe bows round the white necks of the public doves

Let the traffic policemen wear black cotton gloves

He was my North, my South, my East and West

My workingweek and my Sunday rest

My noon, my midnight, my talk, my song

I thought that love would last forever: I was wrong

The stars are not wanted now, put out every one;

Pack up the moon and dismantle the sun;

Pour away the ocean and sweep up the wood

For nothing now can ever come to any good

Ater The Funeral. W.H. Auden

We used to say

That come the day

We'd all be making songs

Or finding better words

These ideas never lasted long

The way is up

Along the road

The air is growing thin

Too many friends who tried

Were blown off this mountain with the wind

Meet on the ledge

We're gonna meet on the ledge

When my time is up I'm gonna see all my friends

Meet on the ledge

We're gonna meet on the ledge

If you really mean it, it all comes round again

Yet now I see

I'm all alone

But that's the only way to be

You'll have your chance again

Then you can do the work for me

Meet on the ledge

We're gonna meet on the ledge

When my time is up I'm gonna see all my friends

Meet on the ledge

We're gonna meet on the ledge

If you really mean it, it all comes round again

Meet on the ledge

We're gonna meet on the ledge

When my time is up I'm gonna see all my friends

Meet on the ledge

We're gonna meet on the ledge

If you really mean it, it all comes round again

Meet On The Ledge - Fairport Convention

Good Times, Bad Times

Reading a book about John Snow, the great 'Medical Detective', and GasPasser, I came across some good old fashioned vituperative medical journalism. It seems both more genteel and more cutting than what one sees today.

Which is mostly about how shit and overpaid we are.

It makes me cross when I read articles belabouring the point that some Docs get paid large sums, as if this were an offence to God. If we do a good job, why should we not be paid well; why should we, just because we work in the public sector be paid lower wages?

I lack the energy to debate that fully.

But how much is it worth for us to save your child's life?

Fuck that; if your kid breaks his arm, how much is it worth for us to take his pain away?

How much for us to look after your daughter when she's too drunk for you to cope with?

I get paid to work long hours, and deal with shit you don't want to.

For no good deed goes unpunished.

That having said, I generally find that a polite manner, regular explanation and other interventions of a tree hugging nature are enough to produce a smile ad word of thanks from most of my patients. Handing out Teddy Bears to scared kids, and watching their shy grins as the take the bears, without letting on that they want them, is good value.

Yet for every patient who is grateful for what you do, there is the yang to this yin. There are patients who are, frankly, penises.

Just tonight we spent a goodly time wrestling with just such a man. He dedicated his Friday night to imbibing his own bodyweight in booze. He then topped that off by passing out between a couple of parked cars, where a helpful passer-by happened upon him.

he was wheeled into the ED, full of drunken cheer, shouting to all who would listen, a drunken sailor, king of all he surveyed, and pleased and excited to be on this next part of his beer fuelled mission.

However, shortly afterwards he decided he wanted to go home.

Clad only in his pants, unable to remember his own last name, let alone where he lived, or where that was in relation to where he was now, also a mystery to him, he resolutely insisted he could, and would go home.

Big deal, you think. Let him go....

Fine, if he could stand.

He demonstrated his inability to perform this basic task by butting his head into every available surface, all the while shouting 'What the fuck?', like some low rent Phillip Seymour Hoffman.

Now, I don't care if you wanna drink yourself into a coma; that's fine.

Go ahead, knock yourself out.

But if you end up in the ED, at least have the decency to sleep it off, and not blame me for the fact that your legs don't work

La Belle Fille

La Belle Fille follows me occasionally on the interweb; she is always keen to know what "her character" has been up to.

Here's something of a rundown.

Last week, she, and her partner in crime, Jim were gigging near their home town. LBF has a voice that makes other voices weep into their pints with envy, and she and Jim harmonise well. Now, it should be known that my taste runs to the eclectic, at best, and i have no musical talent at all; so all of my comments should be taken within that context.

They should not, in case any Antipodeans are reading, be considered as attempts at "coaching".

Their harmony sounds very natural; it sounds so natural that I imagine it is either genuinely natural, or the product of much hard work.

Anyway, they hugely kicked ass, and LBF actually silenced the pub with some a capella Kate Rusby. I managed not to disgrace myself too much, tho I did drink a bit too much and shout something about Austrians.

In other LBF news, she is considering doing a Burlesque dancing course.

Make of that what you will.

A Little Adverising

Climb Kilimanjaro.

Specialists for Kilimanjaro and Meru Treks, Kilimanjaro by all routes: Marangu, Machame, Lemosho, Rongai, Shira, Umbwe.

A good friend of mine. I commend him to you most highly

"Gentlemen, I Have The Pleasure Of Informing You..."

**For reasons that will become apparent to her, I would sugest LBF doesn't bother with this post. Her character isn't in it. I also know that now I've written this, she'll read on...**

The aortic aneurysm is a pathological entity to be feared. A weakening of the walls of the aorta, the body's main artery, the original big red, if you will, allows it to stretch and swell, to bulge. Think of old school Tom and Jerry cartoons where Tom stands on a hose, and the hose swells comically behind him.

Except it's less funny.

I shan't bore you with the details - you'll either know them already, or not want to. But the only curative therapy is surgical, and that carries significant risk. Some cases are felt 'inoperable', or carry such high risks as to be felt inadvisable.

Of course, the risk is that, like the hose, the aorta will eventually burst. And given enough time, it surely will. Such rupture carries with it a poor prognosis. For some, who we might consider the lucky ones, the rupture is catastrophic, and the end immediate, the spirit carried away in a rush of blood.

For others, the rupture is less dramatic, a slow leak, if you like, or the flow of claret is contained. These are the fellas who make it to hospital, the ones who might make it onto the table.

Might.

I am increasingly finding patients with anuerysms who have a "no surgery" decision in their notes. These decisions were invariably taken some time in the past, when the patient was well. I was not present when these decisions were made, so can't tell you how it was sold to the patient by the Consultant, or, increasingly, Vascular Nurse Specialist.

I don't know if this pre-emptive decision, this advanced directive, is being made more often; I just have quicker access to notes and clinic letters than ever before, so maybe that's it.

Now, I'm not a vascular surgeon, so my opinion on this is not as informed as it might be.

But, here it is...

I think it perfectly valid for patient and specialist to discuss surgical options for elective repair and decide against, either because the patient doesn't want surgery, or because surgery just isn't worth the risk. Fine; super.

But I'm uncomfortable about decisions being made to never consider emergent surgery. To my mind, that decision should be made at the time. I have never yet met a patient who didn't change their mind when it came to the sharp end. A decision that made perfect sense last year when you were pain free, is rapidly forgotten when you're in agony, and frightened. But maybe that's not the best time to make these decisions either, when the tendency is to grasp at any chance for more time.

Nonetheless, I think these case should be judged on their merit contemporaneously; the decision may still be that surgery isn't appropriate, but the harm : benefit ratio has changed dramatically, so surely we should be considering that.

******************
Addendum

I don't quite mean advanced directive in its true sense; I'm all for those. This is more that a decision has been made not to operate under any circs, and I'm not convinced the patients know what that entails... leastways all the ones I've seen barely remembered making he choice, and none thought it was such a great move once they hit the ED.

Counterpoint, I s'pose, is that none of them know what surgery entails, either. I guess it's just hard to tell 'em - your aneurysms ruptured, but you're not having surgery cos you said you didn't want it, and see the look on their faces.

Maybe I'm being selfish. Maybe it's my pain I'm trying to ease