Interlude, Part The Second

Another bad day. Bad for me, worse for others.

I had an unusual case yesterday, wherein a 21 year old lad presented with severe lower limb muscle spasm, and turned out to have bilateral fractured femoral necks; without significant trauma.

Yes, I'm stumped, too.

Today...

the first was a young man, in his 60s, previously well, in cardiac arrest. He had had a colonoscopy the previous day, and returned home without complication; after a few hours at home, he developed severe lower abdominal pain, cramping and colicky, although the notes document that this passed when he opened his bowels and passed flatus.

The notes document that he was symptom free when seen in the ED. He examined normally, and was discharged. Then she couldn't wake him this morning.

By the time he got to us, the Ambos had been working hard for an hour. They couldn't intubate, and I could see why. His jaw was clamped shut, clamped so hard, he'd bitten through his tongue. I couldn't get it to budge a millimetre. Looking down from the head end, I could see my colleagues struggling to straighten his legs out.

No dice.

There's usually only one reason why someone in cardiac arrest has muscle rigidity: rigor mortis. The poor soul had been down for several hours before even the Ambos were on scene, I'd say. We tried, and we tried, but he remained stubbornly in asystole, and his blood gases were those of a dead man.

His wife was utterly unprepared; she pleaded with me to do something, oblivious to my gentle suggestion that he had, in fact, died in the night, and that at best, with a downtime of 90 minutes, even if I could convince his heart to beat, his brain would never recover.

But I couldn't convince his heart to beat.

I knew the accusation would come; she couldn't help it: "He was here last night! Why didn't you see it?"

I had no answer, could barely look her in the eye.

...the second, another young man, found in a collapsed state. Known to be a fitter, prone to slow recovery, he looked post-ictal, but was too slow to come round. He gradually developed some focal signs, his right side becoming tense, spastic and useless, his conscious level ebbing away.

The diagnosis of a prolonged post-ictal phase began to ebb away. CT confirmed what we had all thought: a sizeable intra-cranial haemorrhage. Neurosurgery wasted no time in pronouncing no hope for meaningful recovery. They did offer to take him, to try a ventricular drain, but stressed this would be to prolong duration of life, not improve the quality of that life.

As we pulled the tube, and placed him on his side, I'm left to reflect: two sets of lives ruined, and not even lunchtime. Difficult to put a spring in my step today.

On Perspective

I do have a serious (ish) point to make; but the heat is making me sluggish. Everything seems a bit harder when it's this close and muggy. Even my coffee mocked me this morning - the milk looked good, smelled ok (ish) and, on adding to coffee, seemed good.

Sadly, it tasted like shit.

So, a few days ago, you will have noticed - unless you live in a cave, or are deaf dumb and blind, and spend all your days playing pinball - someone famous died.

Well, two, really. Farrah Fawcett, and Michael Jackson both shuffled off this mortal coil. On La Belle Fille's birthday, as it happens, but I'm sure that was a coincidence. Farrah's death slipped by me un-noticed. Not entirely surprising, as her people have no real reason to keep me in the loop.

Jacko, on the other hand, was a different matter altogether.

I was working lates. Unintentionally late, as it went. I thought I was on till two, so turned up at 6, only to discover I was on till midnight, and should have been on at 4. Still... I think if I hadn't been working, I'd have missed it. But nowadays the concept of a 'scoop' news story is obsolete. I still recall films where reporters at a Courtroom, for example, all rush to the bank of PayPhones (remember them?) to try and be the first to get the story back.

Now - the story, whatever it may be, is flashed across the globe at the speed of light. The internet has made us all neighbours.

But there's still an odd feeling when something is breaking. The news began as a sort of ripple, word of mouth. People whispering, asking 'Have you heard...?' (which sounded like it ought to be a joke, and soon was...)

I was in resus, with a patient who had collapsed at home. Fitted, stopped breathing, tubed without drugs, still not responding an hour later, BP steadily climbing...

I didn't need the CT to tell me what had happened, but we have to get it anyway; it showed, as I knew it would an huge, catastrophic mass of blood in his head. Unsalvageable, unsurviveable... there's no way to put it that doesn't sound awful.

What follows, what I hate doing, is the telling of the family. Then what's worse is pulling the tube. Until that moment, he looks as if the vestiges of life are still there. His chest is rising and falling, in time with the wheezing of the vent, and he's warm.

But I have to pull the tube, and I know he won't breath by himself. I only hope he won't choke as I do it, only hope that his reflexes have gone, to save him the final indignity.

His family gather around him as his heart beats his last.

Later, after the paperwork is done, and after I have seen confirmation that Michael Jackson has gone just as suddenly, the family seek me out to thank me; I look from them, who seem shocked and unsure of what they'll do next, as they walk slowly out into the night, to the pictures on the computer screen, of hundreds of folks outside UCLA (or wherever it was).

I'm sure there's a meaningful comparison here, if only I could find it.