Learning On The Job

There are, it seems, some lessons you have to keep on learning. Unlike to aphorisms pertaining to those in possession of a blue rinse, or wearing sunglasses indoors, at night, some things keep cropping up.

Lesson One: History is important

We are taught this almost from day one at medical school. Diagnosis is mostly in the history, and the skill, the art, is in teasing out those details that give you the answer you seek, while ignoring the dross, the red herrings. Refining the art allows this to be done at speed. You might call it pattern recognition. I like to think I'm good at it.

And yet...

She fell at home, a simple fall. What we call a 'mechanical fall', much to the consternation of my Physician colleagues. She bumped her head, but did not black out. An Ambulance attended, the Paramedics found her uneasy, but otherwise well, and settled her into a chair, left her with her husband. A little later she had what is often described as a 'funny do'. She missed her mouth with a piece of cake, and just wasn't herself. By the time she arrived in the ED, this too seemed to have passed, and she was her old self again. No amount of prodding and poking, pushing and pulling, no light cast into the darkness could illuminate any abnormality.

The history, however spoke volumes. The textbook history is a head injury accompanied by LoC, then recovery, then further, and often final lapse into coma. Natasha Richardson walked this road. It is a history that whispers of bleeding within the skull, typically an extradural haemorrhage.

This history didn't quite fit, but the pattern was close enough, and set the voice in my head a-chunterin'.

I mulled this over; our Radiologists are often less free with their CT scans than my North American colleagues, and, even with a suspect history, I wondered whether the normal examination would preclude what would have been an out of hours scan... Perhaps I should have asked them? I didn't. I elected on a middle path, admission for observation.

I didn't have to wait long. Inside 10 minutes, she was unresponsive, and 10 minutes after that, her right pupil had dilated, mocking my decision. Her subsequent CT scan confirmed my fears, and showed in ugly monochrome an extensive bleed. It was subdural, not extradural, and the Neurosurgeons took but a few minutes to tell me there was nothing to be done.

Should I have held true to the history, and pushed for an earlier scan? Probably, yes, although it wouldn't have changed the outcome. Would it have been better for her to know what was brewing within her skull? I'm not sure, but maybe goodbyes could have been said, last words spoken, a few minutes spent settling accounts. Maybe that would have been worth it.

Maybe. Sometimes 'what if...' is the most painful phrase you can say to yourself.

Lesson 2 - People with pathology get sick too

She was young and a known fitter. Brought in because she had had a fit. People who fit, fit. Shroom's aphorisms. Sometimes there's another reason, usually benign, mostly there's not. Make 'em safe, watch 'em wake up, and send 'em home.

What if they don't wake up?

When nothing else seems out of kilter, should you scan 'em? Now, later, when?

I waited. Gave her an hour. The law of Sod, says if you call for intubation early, they'll be awake by the time ITU get there; if you don't, it'll turn out you should have called early.

I waited.

After a bit, the patient gave me a nudge. Her pressure stared to rise, and she started posturing. 'Posturing' means she stared making atypical, abnormal movements with her limbs. Not 'I'm waking up now' movements; more 'my brain is bleeding' movements.

A quick tube and CT later showed a head full of blood. A sub-arachnoid haemorrhage.

I waited because she was a fitter. Did it make any difference to outcome? I don't know. I hope not. Interestingly, my Radiology colleagues, whom I have upset with a variety of requests for out of hours CTs this week, were sceptical about scanning her, for precisely those reasons. She was a fitter.

A wise man once told me you have to try harder with certain patients: the frequent fliers, the rude and annoying, and those with pre-existing pathology that masks the assessment. Because they too get sick, and sometimes we don't look hard enough