Swine Fever

Contains Nudity. You've been warned...

'So, we've asked the Police to pop round and see you. O.K?'

There are few, if any, times a body will be pleased to hear that. I suppose if you're being forcibly pillaged, you'd be glad of the presence of Her Majesty's Constabulary. But I'd cautiously suggest they wouldn't be 'popping' round under those inauspicious circumstances.

Anyway, how did we end up here?

The BatPhone trilled away; the call slightly unusual. 'Young male, GCS 3, ?swine flu'

For those less in the know, 'swine flu' is the current strain, H1A1, of pandemic influenza. Complex protocols exist for it's management, and more importantly containment. These are hard to enforce when your patient is critically ill. The GCS, or Glasgow Coma Score, measures one's conscious level; 3 is the lowest. It is safe to say GCS 3 suggests critical illness.

The history we had been provided with offered few clues, but more details were forthcoming. It transpired our patient had collapsed in a shop. He had popped in the previous day to brighten the tedium of the checkout girls and boys by proclaiming to all and sundry that he had swine 'flu.

And then leaving.

Today, he had gone one better, striding manfully into the shop, stark, bollock naked.

Skyclad, if you will, possibly in honour of the Solstice.

Nudity is always funny; fact.

Sometimes, not for the reasons you think it is, but it's always funny.

Random nudity is usually enough to create a talking point. Or stop conversation. It gathers a crowd, anyway. Occasionally stops traffic. A well endowed female patient of mine once fled my care, for fear of the Military Police, clad only in a tiny thong. Several taxi drivers stooped at the ED, all asking 'guess what I just saw', all disappointed when I guessed...

In this case, onlookers assembled, and our our Nude Ranger coughed heartily on them all, then passed out in a small pile of his own vomit.

Matron and I met him in the Ambulance; the crew were masked up, and had little more to offer. The decision we had to make was how ill he really was, and might he really have flu. Of any sort.

Our initial assessment was promising: it's hard to explain, but there's GCS 3, and then there's GCS 3; one really is coma'd; the other... you get the feeling that they just don't want to respond. The rest of his obs were normal, and he looked well... just... sleepin', sorta.

A little 'gentle' pressure to the nail bed, to establish his response to painful stimulus, one of the components of the GCS, transformed him from 'flu-coma' man, to angry confused man. A startled naked man with a sore finger sprang, like a 21st Century Lazarus, straining against the restraints designed to stop him falling off the trolley en route.

He launched into what I have come toi think of as the waking coma victim's litany:

'FUCK!'

'Fuck off! Fuck. Fuck, FUCK!'

'FUUuuuuckK OFF!'

'FUUU... Hey, where are my fucking pants?!?'

This erudite conversation dealt with, and reassured that he was no longer in coma, we tried to find out what had brought him, in all his pink glory, to our humble establishment.

Unfortunately, he was trying to figure this out, too.

Waking up, to find a pasty man in green scrubs crushing your finger, and two Ambos in masks leaning over you is not well designed to reset your normality.

He wouldn't fess up to any illicit activity (they never do; I suspect they think we'll shop them), and was confused as to his whereabouts; and the whereabouts of his pants.

He eventually coughed to having smoked some weed that morning, but was sure this had had nothing to do with him proudly patrolling the high street, playing willy banjo and passing out.

In case he had ingested something else, we decided to call his girlfriend.

She was also in, shall we say, an advanced state of refreshment; highly relaxed. More to the point, unable to offer any coherent sentences that might aid in our quest to guess the drug. In fact, she was convinced he was still in the house with her. It was this, slightly frustrating, slightly circular conversation that prompted Matron to suggest we'd send Plod round to talk to her face to face.

Now, I respect the kind of fella who decides he's going to spend Sunday getting ripped to the tits on drink and drugs; indeed, it takes a real effort to get so banjaxed that you tear all your clothes off, and bestride the High Street with your balls swinging back and forth by ten in the morning. But I'd rather you didn't bring it to where I work.

I did feel slightly sorry for his lassy tho'. After being called because a loved one has died, I imagine she enjoyed the prospect of the Boys in Blue at her doorstep less than most.

Paranoia Strikes Deep...

Yesterday morning was spent trying to talk down a spectacularly paranoid fella, who, when he wasn't freaking out because he thought he was blue, was challenging my status.

His exact words?

"I'm not being funny, yeah, but I don't even think any of you are real doctors. I mean, you're all wearing trainers, for fuck's sake!"

Finale

Wimbledon is going to the wire as I write...



So - yes, a fractured clavicle, which was spotted; but as the second recall X-Ray shows, a few busted ribs too. Try as I might, I cannot see them on the original, even with the advantage of digital viewing, denied you guys...




It's still not a brilliant image, but I think you can see the healing right sided rib injuries. Thankfully, no underlying lung damage.

Nights pass, as they do; Friday was busy for TooTall Student, so I think she got a good flavour of the ED. My main flail was trying not to call her by La Belle Fille's name... We ended on a Shroom 8 a.m. special. Just as we wound down for handover, the call came in, courtesy of BatPhone. The real deal - 40s, cardiac arrest 15 minutes away. !5 anxious minutes to try and gear up, try and get your mind running again. The nurses change at half seven, so they're fresh, but we medics all smell a little fusty. It's an odd scenario, as the bustle in resus goes on with the night guys drifting out, saying their goodbyes, making breakfast plans...


As our patient arrives, so do the day staff; we're short handed at weekends, so I stay and DayReg takes handover; he floats on the periphery, filling in the little details that my morning brain can't quite fix on.


The damage - a young fella, we think he has Wolff-Parkinson-White, an electrical short-circuiting of the heart, predisposing him to arrhythmia; we think he may have taken some drugs... we know he was found down at 7, we know he had no output at quarter past. He is unceremoniously dumped on our trolley, the Ambos herding round, bright-eyed, a sheen of sweat on a few brows; they've done their bit, and done it well. They know this, and don't need me to tell 'em, but want to know if we can finish what they started.


Chaos ensues, for a minute or two, checking the tube, forcing air into unwilling lungs, hands slipping on his greying chest. Then, we pause, come up for air, re-assess.


Got him.


Weak, yes; thready, yes. Hardly a thing to be proud of, but he's got a pulse. His rhythm is crazy on the monitor, never staying in one place long enough to get a fix. More drugs, more air. ITU and Cardio arrive.


Lost him. Four more frantic minutes until we find him again, pull him back over the edge. ECG shows a large MI, and we know why; the CathLab is being warmed up - we have indeed moved into the 20th Century - but I'm not sure we'll get him there.


Thankfully ITUMan is. He doesn't strike the epitome of cool across the room, but he is. Collected, organised, he casually takes over... and I am glad. Slowly, the patient heaves to, listing a little, for sure, but slowly doing what we want him too. ITUMan disabuses me of some ideas about the properties of fentanyl, and I feel generally clumsy next to him. I blame my 8 a.m. brain.


No matter; just under an hour later, he rolls out, with our patient, stable for now, onward to the CathLab. From what is undoubtedly at least two people's public tragedy, we are all smiling. We've done well, here today. Done what we were paid to do. We don't know if it will make any difference in the long run, but that's not our job. A little messy, disorganised? Probably; I expect I shouted a bit too much, too, but he came in dead, and went out alive... cliched?


Sure, but right now, I don't really care.


They're still on at Wimbledon...

Everybody Wants It, Or Has It, Or Knows Where To Get It

More on time; I can't be sure of the quality of this post. I always mean to edit, but rarely do. There is an interesting picture tho'; I can promise that.


The medicine first; you can switch off thereafter.

Back on nights. Lovin' it. New guys, and gals, means more questions, all at once. Slower times. I set a new record. The entire board was full, 20 patients, ALL waiting to be seen. Awesome. Funnily enough, no-one was proud of me.


One of, if not my biggest, flaw, is my propensity to arrogance. I think I'm good at my job, and when it goes well, when the world falls into synch with my version of things, I get easily carried away. Sorry.


Anyway, I like nights. BBP was back on, and I thoroughly enjoy working with him. Not only is he good at his job, he's fun to work with, and gets some of my humour that otherwise falls very flat in the Department. Not all of it, and he might just be humouring me, but...




The picture:




One of many I have, that should not exist. Medics among you can probably guess.




The scenario:




A young man, stabbed in the chest. Single chest wound, left side, posterior, infrascapular. On scene, agitated, hypotensive, tachycardic, hypoxic. Scooped and run.


On arrival; distressed, pale - deathly white, you might say - waxy. Airway patent, spilling forth garbled words. Respirations ragged, fast, shallow. His left chest running a beat behind his right. Trachea midline, but the left chest quiet, oh so quiet. Normal percussion note.




Pneumothorax.




But he's shocked...




Where else is he stabbed? X-Ray light the room up as I probe, urgently, hurriedly.


I can't find anything; X-Ray lights up the room again, telling me I can stop.

So: for the non-medics; this is a tension pneumothorax. The term pneumothorax literally means air in the chest. If there is air outwith the lung in the chest, the negative pressure in the lung will cause it to collapse. Simple pneumothorax. If air continues to leak into the chest cavity, with no route out, it becomes a tension. As the chest has a fixed volume, the air will eventually displace the other structures within the chest. This fella's heart is in the right side of his chest. (as opposed to left, e.g incorrect. In case you were wondering)


It's quite the opposite of where it should be; and it is this that is causing his blood pressure to be low, his pulse to be high, and my adrenals to be in overdrive.


It is a premorbid condition, and should be a clinical diagnosis - hence why the picture should not exist.. The path should be: diagnosis - treatment - life saved.


If it goes ?diagnosis - x ray - treatment, the next step is usually death.




As it was in this case:

(Not one of mine, and followed by successful resus, I hasten to add)

Treatment is simply letting the air find a way out. We put a tube into the chest, syphoning the air away, allowing the lung, literally, room to breathe. I want to teach an SHO to put the tube in; this will take time. So first, we decompress the chest. A large needle, mid chest, straight in. Compared to the tube we're going to put in, this needle is tiny.

In real terms, it's big enough. The patient, bugeyed, doomladen already, finds it hard to relax. Fentanyl to taste sorts this. In fact, he relaxes enough to 'fess up to having indulged in some stimulants.





The transformation post needle is remarkable. Pulse and blood pressure normalise. Always one for the melodrama, I clap SHO Spot on the back, and congratulate her on a life saved. The tube goes in next. Mostly smooth, but she has trouble getting her finger through the pleura. I don't have any tricks; my way needs a little more fent, but the track is made. I am briefly reminded of a Jean-Claude VanDamme film. (I think..? maybe Seagal?) The one in which protagonists harden their hands by plunging them into cauldrons of heated sand. I try to convince SHO Spot that this is why I can poke holes in chests with my little finger, and she cannot.





She almost believes it.





She wants to do Paeds, so I let her off.





As tube goes in, he springs his last surprise - a litre of claret runs down the tube. Hot, urgent, messy. I am struck by the contrast it makes to the claret we put in, which is cold, cautious and dark. The smell of the butcher's shop embraces us again.

Cardiothoracics breeze in, encouraged by the output from chest tube to take a peek. His very presence intimidates the bleeding, and the gush becomes a trickle. Nonetheless, he wins CT angiography. There is no ongoing loss, but I am slightly anxious to see my tube in intimate contact with the aorta...

He's doing well; a good day.

I go to tell his dad. His brother, also stabbed, wants to see him. I explain that the Police have asked, for forensic reasons, that the brothers be kept apart for now. I am amazed to see him actually square up to me. He toes the line, puts his face in mine and extends the view that he, the brother, cares for him, the patient, and what the Police say is of little consequence.

I offer a counterpoint that I, the doctor, have just saved his brother's life, so it is me that has done most of the caring, and the idea that he appears to be gearing up to fight me is slightly shameful. He is undeterred by this tour de force of logic, and I am (probably) only saved from a beating by his dad.

My favourite joke? (Totally unrelated, I assure you)

Q: What do you do on cocaine?

A: More cocaine.

The rest of the weekend was less exciting, but saw me win the 'Guess the sodium in befuddled old ladies' competition, and be called a hero by another patient. (For crawling under a table to get some sponge forceps)

Arrogant, remember.

We also mourned the passing of BBP's trauma shears. He was very upset, and despite us pretending to be shears, we couldn't find them. Mine disappeared the next night, in sympathy, but he was not an happy bunny.

My mouth has run dry. The non-medical jib will wait.

Happy St Patrick's Day tae ye all.

Slainte

A Bigger Picture

I'm still feelin pretty good about myself. I'm sure it won't last, but you take what you can get, eh?

Last night was actually quietly busy. Did I already tell you that? I can't remember... the department was stuffed, but with few real sickies. Which is nice. These days it seems a real rarity if our Resus Bays aren't overflowing.

It doesn't take much, though. Another midnight call, another breathless punter. At the best of times, I'm a resus hog, an adrenaline junkie, an SHOs nightmare. Turn around, and there I am, champing at the bit. No matter how quick you think you are... I'm faster. The SHOs I like the best are there quickly, too. I see in them a kindred spirit; they want to see the difficult cases, the interesting cases. This is markedly unfair to the many excellent docs who come through EDs but aren't especially interested in the Acute end of the spectrum. Sorry, guys. No offence meant.

I digress; the elderly breathless is pretty much bread and butter. Since pretty much everyone smoked in the 30s and 40s, they now all have COPD. If they don't, they have heart failure. As with all of medicine, the devil is usually in the details; history is almost all of it. If they're on inhalers up the wazoo, it's COPD. If their drug cupboard rattles with diuretics and other 'heart' meds, its their heart.

Usually. And for all my esteemed physician colleagues, I know it's never that simple, but it's pretty close, eh?

So, last night's arrival had a long smoking history, several admissions with 'exacerbation COPD', and a cabinet full of inhalers and nothing else.

COPD, right?

So much for history...

As I'm sure my medical colleagues know, these patients also have a look about them. This guy was exhausted, sweaty, cold at the edges and had a sky high BP. JVP virtually punching through the roof.

Heart failure.

Chest... pretty quiet, a few wheezes, a few fine creps. The good old fashioned ED mixed bag.

In short, his history was good for COPD, but his exam spelled heart failure. The difference is rarely as clear cut as we would like. When I was on the house, we used to call the treatment 'nebulised frusicillinalol'. Some bronchodilator, some diuresis, some antibiosis.

I was pleased to see my SHO run it like a pro. Good history, rapid assessment, right diagnosis, prompt treatment. The joy of it is, of course, that COPD-ers need limited oxygen and nebs, whereas heart failure needs as much oxygen as you can cram in, and offloading. Get it wrong, and...

Sometimes, whatever you do, it's too late to stop them circling the drain.

We used nebulised frusicillinalol nitrate. X-ray and subsequent intubation confirmed the clinical suspicion of left ventricular failure.

I spent most of the time with the family; it's one of the good things about having competent SHOs. I hope it's because we taught them something. Because I taught them something? I guess it doesn't matter as long as they learned it.

Blah, Blah, Drugs, Drugs, Mouse

Now none of you need buy, or read, Russell Brand's autobiography.

The Gospel of Shroom: a public service broadcast.