Way To Blue

Yes, I'm back. Again.

Again.

A little housekeeping.

Those of you still here, and keeping up, will have noticed all pretence of anonymity has gone. Well, more or less. I cannot be bothered to go back through all of these posts and remove the fungal refs, but all of these posts now bear my actual name. Those of you who really want to can Google me. Or Bing me. Why not Bing that shit? Either way, I am there. For better or worse. The GMC, they who must be obeyed for the registered medical practitioner, have taken a decidedly dim view of the anonymous online physician. You can make of that what you will.  There's an interesting take on it on The Pod Delusion, if you feel it's worth more than a cursory shrug of the shoulders. Anyway; I'm out. It's probably not that important really; I'll take the opportunity to remind you all that any clinical situation I discuss herein is at least non-contemporaneous, and possibly fictitious. Names have been changed to protect the guilty, and me. If you think you recognise yourself, or someone close to you, you're wrong.

Some things, however, never change. I'm still, mostly, gazing at my own naval, overusing the word maudlin.

Debriefing. I don't know where debriefing first took hold. I want to think its the Military, but I couldn't swear to it. It sounds like it should be the Military, though. The After Action Report.

In any line of work, when things get runny, they usually do so somewhat chaotically, running with an energy all of their own. Even when it feels like you have a handle on things, that control is usually fleeting, or illusory. Without accounting for everyone else swept up in this particular tempest. As a contemporary of mine is fond of quoting,

"Good judgement comes from experience, but experience comes from bad judgement."

So we crave exposure to whatever it is we try to do on a daily basis, crave our own experience, and crave that of others. Hoover it up, in the hope that whatever was done well can be assimilated, copied and pasted into our own experience, ready for deployment next time out; and that whatever was done badly can be picked clean to try and remove it from the deck next time. More than that, it offers a chance to meet with your colleagues when everything hasn't just slipped agonisingly through your fingers. A chance just to sit down, and acknowledge what it was you just did. Sometimes, I think, its enough to look each other in the eye, and have a little cry. I don't think I did enough of this when I worked in ITU; I'm pretty sure we don't do enough of it now. Sometimes, we can't meet each others gaze. We (I) aren't so good at the more empathic sphere of what we do.

Recently, we had a tough shift. I can't go into the details, obviously. But most of us, if not all of us, have a 'worst-case' scenario. The patient we fear most; the one that we dread. Even the non Medics among you will have no trouble trying to imagine the clinical situation you would least like to be faced with. This was mine.

Actually, the case was run well; but the outcome was bad. Awful. I don't want to be any more melodramatic, but you get the idea. And debriefing something like this, talking it out, is hard when you're talking it out with people who weren't there, people not in the business. Not because we're special, but sometimes these cases are deeply upsetting, and there may be a reason why the person you're talking to didn't love ER. Or maybe it's a defect of my character, that I don't trust my friends to be able to process the chat in a way that I can; or have to; or think I can. I think there's a danger of casting oneself as the martyr, then. The only one capable of managing the psychic trauma.

Which is bullshit; I'm not that special.

Back Again

So, I've been away; there may be clarification as to why in the future; we'll see.

It seems to often be the way that the patients you really like end up with the shitty end of the stick. I saw just such a patient yesterday; we had seen them a few days before, and sent them on their way, reassured with a simple diagnosis of 'constipation'

I dislike 'constipation' as a diagnosis; to my mind it's a symptom, but I guess that's open to debate. We all have our own foibles, or pet hates, or what have you. This is one of mine. I think it's more important the more elderly the patient is, and that's built on a deal of experience, but I recognise that 'in my experience...' are dangerous words in medicine.

Anyway; the patient was at least of pensionable age. I subjected them to an 'end-of-the-bed-ogram', and concluded that they looked pretty good, actually. Sitting in a chair, chatting happily to the MedStudent. Not gowned and trolled by the nurses, which often says something in its own right.

The tale; ah, well, its all in the telling. I'm not sure how sensitive, or specific, my 'gut' is; clinical gestalt is supposed to be pretty good, but one only tends to remember the times when you get it right, or are proved wrong spectacularly. The patients about whom you really worry, but turn out fine, tend to fade from view.

Anyway: this tale, of gradually altered bowel habit, loss of weight, loss of appetite made me anxious. And lying the patient down, removing the bulky pullover gave the lie to the idea that they looked 'ok' when sitting in the chair. The drum-tight belly, empty rectum and slightly hollow, pale eyes tell a tale all of their own.

Throughout all of this, the long wait, the uncomfortable, undignified examination, the merciless poking of the blood tests, this apteitn remained cheerful and upbeat. Grateful. Chipper.

I really like them.

So, it came as no surprise when the belly film confirmed an obstruction, the gas pattern neatly nipped off around the mid descending colon.

Of course, I don't have a diagnosis yet, but the probabilities hang heavy around my neck.

Shaking What You've Got

Another interlude. Typing on my iPhone, so may be shorter than usual. It's awkward, and the events herein upset me.

On how things go wrong, and on not knowing.

The patient, hypothetical as always, might have been middle aged and in renal failure requiring regular dialysis. Imagine they present with a nosebleed. These are the patients who carry a burden of hindsight with them. It is neatly packaged, and in my experience you won't see it unless you're careful.

Patients with open fractures, overdoses, an overcrowded Paeds Department: all of these things might get in your way, might cloud your vision.

Suppose the bleeding starts again. It's obviously vigourous; despite packing, blood continues to flow freely, from the other nostril and from the mouth, obviously coursing down the back of the nasopharynx. Threatening to choke her, but not quite making good on this threat.

Imagine you can't see anything to cauterise; more packs? A foley to tamponade posterior bleeding? Something I've not done much of. Will it make it worse?

Patient is stable; call ENT. You will tell yourself it makes the most sense; you have other patients, this one is ok (now) and needs an expert.

Half an hour later, you're bagging the patient; the airway resembles an abattoir. The tube goes in ok, and maybe 10 minutes of CPR will get him back.

But your patient came with a nosebleed, and arrested while you watched.

Could I have done more? Should I have?

I feel like I'm burning out

These patients, hypothetical as they are, are the ones that will challenge your very soul.

If you still have one.

Interlude: Referral Politics 2

So: the last of the epic tales of my on call.

I knew I'd be late on the floor; 2 down and busy, no way was I getting off on time. Half two in the morning is close to my limit. If there are sick patients, well, strap on when it seems apt, but if its just busy...

As I was preparing to escape, I was introduced o one of my absolute favourite ED dilemmas. The 'problem' patient that no-one will admit, or discharge. Typically, this will be someone well known to one service, or more than one, with a chronic problem. They inevitably attend out of hours, with a flare of their problem, usually requiring strong painkillers.

In this case, the problem was abdominal pain. Surgical review diagnosed "not a surgical problem' with a plan of "refer medics'. But of course, the surgeon couldn't possible make that referral. Since the problem is "not surgical", the patient reverts to us.

Medical review resulted in a diagnosis of "not a medical problem", with a proposed plan of "have the surgeons admit, and we'll review"

This backing and forthing can go on for days.

It is a waste of everyone's time, especially my registrar's.

Usually, a polite call is enough. It makes sense for the two specialities to talk to each other, and agree a mutually acceptable plan, or discharge the patient.

Being a consultant, it has the added advantage that I can always suggest if they don't want to talk, I'll call their bosses in, and we three consultants can review the patient at the bedside, and agree a plan. After all, I'm still here at 3 a.m., I'm sure their bosses wouldn't mind coming in to join me?

Well, I left them talking, which doesn't guarantee resolution, of course.

But I'm hopeful.

There may be some follow up here.

Don't touch that dial.

Interlude: Referral Politics

Ah, the joy of the referral.

Times have changed. The all powerful target means less time for us, in the ED to reach a diagnosis; often the decision to refer for admission is based on a lack of a diagnosis, coupled with the fact that the hospital says I can't stop and think.

And so, the soft referral. I like to think that most of my referrals are kosher, and if I'm not sure, I'm honest about it. But sometimes, I just don't know what's wrong with a patient, but I'm pretty certain they need longer obs than I can offer in the ED, and maybe more tests. (More tests! The answer to everything!)

I had just a conundrum recently, and was given a hard time by the MedReg. Not necessarily inappropriately; I really couldn't figure out what was afoot, but I tried to be honest about that, and why I though the patient ought to come in.

Her SHO, one of our old trainees, told me a few days later, that she hadn't realised to whom she was speaking, and had been apologetic thereafter. (Apologetic, or worried that I might complain?)

This, of course, if bullshit. If she was rude, and I didn't think she was, especially, then who i am is irrelevant. No mater what some practitioners seem to think, there isn't a sliding scale of how rude you can be to someone, based on their job title.

If, on the other hand, she thought the referral was shit, who I am is equally irrelevant. Shit referrals transcend all boundaries.

Anyway. Last week, I'd seen a young girl, complaining of pleuritic, left sided chest pain, shortness of breath and cough. No temp, pulse 120 bpm, resps 30. Normal bloods, normal chest XR, normal gases. Despite her normal gas, I was still concerned about PE.

(The arterial blood gas measures oxygenation of the blood, and, in pulmonary embolus, should be abnormal.)

The MedReg was distinctly unimpressed, and wanted to know why I hadn't asked for a d-dimer.This is a blood test that, if positive, may indicate the presence of clot. It's more often used to rule the condition out, as it is more commonly negative when there is NO clot, than it is positive when there IS clot.

However, in certain circumstances, where risk is perceived to be high enough, even a negative d-dimer isn't really enough to rule out PE. This is, broadly, Bayesian probability, which deals with pre test probability, and how the result of a given test influences that figure to generate post test probability.

So for example if you have a 15% chance of having a PE, and negative d-dimer would allow me to reduce that below 1%, and I might say that's enough to rule it out. But if the pre test is higher, maybe 50%, then with a negative d-dimer, your post test is only maybe 5 or 6%. Enough to rule out?

I think not.

We backed and forthed on this for a while. Ultimately, it came down to, if she doesn't have a PE, why is she in pain, tachycardic and tachypnoeic. I CAN"T send her home. If she settles in 12 hours - brilliant. If she goes home and dies...

Not so good.

Now, I'm pretty boring, so I'm happy to talk Bayesian probability theory, and the evidence behind d-dimer all night. But it occurs to me that my juniors probably notsomuch, and this was all a bit hard work, for what may have been a soft referral, but was, at the end of it all, a patient with ongoing symptoms, and abnormal vitals.

I've seen cases like this before; not many. One or two, maybe, but that's all you need to know that sometimes what seems unlikely turns out to be real.

And I'm happy for a few uppity fellows to think me a por diagnostician, in exchange for avoiding the coroner's court.

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.

Best vs Worst

No further rigors, no idea what the source was. Slightly worried I'm harbouring something nasty... but declined investigation so I guess I have to lie in my own bed.

Increasingly find myself gripped by malaise, and dark feelings of hopelessness, which is somewhat self-indulgant considering my situation versus how it could be.

Anyway, blame that for this post.

In general, I have a low opinion of humanity. Essentially, I don't think we're as far removed from the beasts as we like to think we are. Left to our own devices, I think most people will happily crap on their fellow man, if it's to their own advantage.

Altruism, generosity seem to me to be the exception.

La Belle Fille firmly believed quite the opposite; she does have a bright shining soul though. She may be right.

I suspect my job biases me.

Certainly LBF rarely encounters stuff like this: I was wary of telling this story, because it's sensitive, but I've seen it reported in the Daily Mail, which I think makes it common domain.

A young man died recently, and he probably didn't have to. Maybe it was his time, but he was awful young. He fell into a pond. The Mail reports he had an history of blackouts; I heard seizures. Semantics, really. If you were very uncharitable, you could argue someone with that history should probably stay away from unfenced bodies of water unsupervised. I assume he was alone.

I could be wrong.

Anyway, he fell in the pond, and was unable to get himself out, likely because he was unconscious. It took 25 minutes to get him out. No-one would go in after him.

The Mail is quick to chastise the EMS, whose bosses won't let them go in, in situations like this.

But someone called the ambulance. People stood about and watched. No-one, no-one even tried to get him out.

Stood and watched him die.

Music Nazi recommends Eccentric Soul: The Prix Label.

"You shall not pass!"

One of, if not the most difficult things I have to do is watch people die.

This, clearly, is never easy, unless you're a psychopath. (I am not)

Sometimes, it is expected; after all none of us live forever, and so sometimes it doesn't feel so bad. Especially if you can make that passing as easy for all concerned as possible, and sometimes you can.

But sometimes, you have to watch people die in the knowledge that they shouldn't be dying, and worse, that you don't know why they are, or that you can do nothing for them.

Because what we're supposed to do, is stand there, Gandulf like betwixt patient and death. Only sometimes, you're not a wizard, you're an impotent old man, with a wispy beard.

This happened once before when I was here before, in a different time, or a different life. We then, and still do, as far as I know, take dive casualties, as we have a decompression chamber on site. It might have gone.

The problem with decompression illness is that usually you are too sick to transfer, and will die without transfer. I don't know if there's a answer. I certainy didn't that day.

The patient was a young woman, with, probably, The Chokes. It's like The Bends, but involving your lungs, or the pulmonary vessels. It's having a massive PE with the only treatment a massive metal tube, too far away for me to reach.

She was blue, with crushing chest pain, hypoxic, hypotensive, dying.

I knew why, and I knew I could do nothing about it.

I've never felt so sick.

Then she got better. It was nothing to do with me. she just got better. I guess the gas emboli in her pulmonary vessels just... broke up.

Maybe God looked over my shoulder, and felt our pain.

Death passed us by that day, and I still don't know why; maybe that's best?

Hard Times...

Sometimes shit just happens.
I know this to be true, and mostly use it as a defence, to protect my fragile mind, but sometimes, sometimes, things leak through. No man is an island, and this man certainly isn't a rock.

The Christmas period was as horrendously busy as I've ever seen it, and I've worked a few Christmases. The rest of the hospital seems to operate a fingers-in-ears policy; interestingly, a few weeks after Christmas, when all the patients we'd seen had been admitted, and the burden of care was shifted up a level, 'they' sat up and took notice.

Suddenly we were flooded with extra staff, and, as is so often the way, they came on a day when we had precious little to do, having admitted all the sick patients in the area.

Until, of course, after 6 p.m., when everyone goes home.

Except, me.

We've seen a lot of very sick folks in their 20s and 30s, with awful, awful pneumonias. At first I though it was all 'flu related; the histories seemed to fit, and indeed some of them tested positive, but more of them are testing positive for strep. pneumoniae, which I haven't seen before.

Anyway, this shift, the BatPhone went off, twice in quick succession, forewarning of 2 such patients; one slightly older, one younger. The older of the two arrived first, and looked o.k-ish, just confused, in a lights-on-no-one-home sort of way.

The second, a young 'un, looked really sick. All numbers awful, half-dead in the bed already. I had to take no. one to CT, so left her in the more than capable hands of my Registrar and the ITU team.

No. one's CT checked out ok; I'm still not sure what was going on there, but when I came back, no. two had active CPR ongoing. The guys had been trying to site a central line, when her BP dropped from bugger all, to fuck all. A subtle, but important distinction.

Well, we worked as hard as we could, for as long as we could, but nothing worked, not even a flicker.

I hate losing the young ones, especially when I'm not sure why.

The conversation with her dad, was as hard a conversation as I've ever had.

Cases like this leave no-one untouched. They spread ripples of shit everywhere; they can destroy families, and ruin perfectly good clinical staff, like the Reg I left in charge of the case, who is more than capable, but will be asking himself what more, what else he could have done for weeks.

Maybe it's selfish to think of ourselves, but we can't help it.

We're not supposed to lose these ones, and it hurts.

It hurts, but I suppose it's not so much the falling down, as the getting up again afterwards.

Rode Into Nazereth...

I have had to admit, or at least refer for admission, a number of patients recently in a genuine display of Cover Your Ass medicine. I hate practicing CYA medicine, and yet it seems to form an increasing part of my practice. Evidence Based Ass Covering.

Increasing seniority brings with it a diminishing ability to be wrong. Mistakes are allowed, almost expected of junior staff, and as long as they aren't disastrous... well, you know what I mean.

However, the ever increasing pressure of the 4 Hour target (All Hail) gives me less and less time to think about what's wrong with, and what's best for my patients.

And so, I end up referring those folks who just aren't right. I am losing faith in my clinical acumen, because I know I can't always be right, and I can't afford to be wrong.

Of late I have seen a number of folks who present with odd neurology - non-anatomical numbness, or transient, fleeting symptoms, or symptoms that just don't match the signs.

And they are almost invariably drunk. And will deny this.

I am sure they have no pathology, but I can't send someone home who is telling me the whole right side of their body is numb. Can I?

And Death Followed After

More evidence, if any such was required, that I attract trouble, that I am a 'Black Smoke' Registrar.

'Twas darkest night, tho the moon shone bright (which may be oxymoronic), when the clock struck shit.

That's right. I said the clock struck 'shit'. I would like to propose the term 'shit o'clock' to represent the time in the Department when the shit hits the fan. I suppose 'arse o'clock' would be acceptable, or indeed 'trouble o'clock', if you are less foul mouthed.

Anyway, all had gone just fine, until shit o'clock.

The BatPhone rang trilling of the impending arrival of a young sailor who had fallen 20 feet from a gate, part of which had detached itself and landed on his leg. He had, somewhat amazingly, avoided other injury, but as we peeled back the splinting on his lower leg, it became apparent that that was more than enough.

It was shattered, ivory white splinters of bone prodding obscenely through what was, under the circumstances, a relatively neat wound. It really was smashed.

It was then that the BatPhone belched into life again, this time announcing the arrival of a woman stabbed in the neck, and shocked.

While still digesting this, the Phone sounded again, this time forewarning of a patient in drink, having sustained a head injury, and with a GCS of 3. The paramedic calling chose an unfortunate turn of phrase to indicate that the patient was in Police custody.

"In drink, head injury with GCS 3; oh, and he's arrested."

So I was significantly relieved to see him full of pulse and breathing when he rolled in, seconds after the stabbing.

I barely noticed the arrival of the second stabbing victim

Missed It (2)

A healthy dose of schadenfreude.

A patient with end stage COPD rolled in. She also had a pulmonary malignancy, for good measure. The usual story - gradual deterioration, struggle to manage at home, sudden failure and collapse.

The Ambos reported low sats, recovering with hi-flow oxygen, but a fall in GCS concomitantly.

We see this a lot. I raised my eyebrows, ran the ABG. Acidotic, pCO2 15, pO2 15; both too high, too much O2. Turning it down, we aim for sats in the raange 88-92. Air entry thru the chest is poor, tight. I put it down to COPD, rack up the nebs, quietly confident.

We'll have her up and running in no time.

10 minutes later, I'm wrong. She's gone downhill fast; cyanosed, moribund, circling the drain. Fortunately, the X-Ray fairies have just been, and I gaze at the film.

Pneumothorax.

We know it happens, know they're more common in these guys.

Still missed it.

Still: gives us something to aim at.

Chest tube slides in, a slightly hurried, messy affair, but I hear the air rush out, and five minutes later, the patient feels well enough to complain about the pain in her chest.

I have never been so glad to hear a complaint voiced.

Must try harder next time.

Missed It

A lot of what we do is pattern recognition. With experience, our diagnostic process moves from the 'scattergun' approach to the focussed, guided by the signs, subtle or obvious.

Often, we rely on bypassing a lot of 'routine' or standard investigation, if the pattern before us stands out strongly enough. Sometimes the pattern shouts at you. An 'end-of-the-bed' diagnosis.

Of course, not all disease choses to present that way. Sometimes the obvious is not what it appears, and sometimes, perhaps often, the presentation is atypical.

Sometimes it's not.

A young man with a few week history of general malaise. Tired, weak, off his food, weight loss. Even a dose of oral thrush. Three days before, he had taken to his bed, nauseated, vomiting, listless.

He lay on the bed, looking like nothing more than a survivor of Bergen-Belsen. Like cancer, like AIDS.

His eyes were sunken, his tongue dry and sticking to his mouth, his respirations deep, and sighing. Pulse weak, thready and racing.

he'd seen his GP at some stae in his illness. It must have been at the beginning, because no-one cpould pass this off as anything else.

I aked the only question that needed asking. His blood sugar was 52 mmol/dl. He has diabetes, until now undiagnosed, and had drifted slowly into keto-acidosis.

There is satisfaction in even this most simple of diagnoses.

Zombie Apocalypse

More evidence, if any were needed, that Great Britain can't cope with snow. And, latterly, that every time I agree to swap shifts with someone, it goes tits up...

Tuesday, two days ago, I should have been on a day off, but had agreed to cover a shift for a colleague. It was the swing shift, 4pm until 1am.

By just after 6 it was snowing pretty heavily, but didn't seem to be settling. By about 8 it was lying thick on the ground, and the flail had begun. Cars were getting jammed on the roads, big and small, and even the Ambos were getting trapped. It rapidly became apparent that no-one who couldn't walk home was getting home.

This clearly included me.

The only upside being that if we couldn't get out, no-one could get in. Ambulances couldn't even back into the Bay, a distance of some 10 feet, up a risible slope, and for a while we either unloaded patients in the road, or relied on 4x4s pulling the Ambos into place.

Just when I thought it couldn't get worse, we ran out of food. Management did their bit and pitched in with a plate of sandwiches. Fortunately, saner minds prevailed and we ordered in pizza...

And then... the power went out. We were, I'm told, struck by lightening. Twice. All the lights went out on majors, and it was all very M*A*S*H - medicine by torchlight. It was at about this moment I was expecting the zombie apocalypse, but the only pallid figures wandering the corridors were the staff.

A few rooms were cleared, and we all bedded down. This was not the sexy night-time hospital orgy it might have been if my life were a film, or if I were not blessed with LBF.

The next day wasn't much better, although numbers were still down, and at least after a double shift the roads had been cleared enough to get me home.

It's still pretty icy out there, and we, as a country still don't really know what to do about it, so the upcoming weekend nights should be a giggle.

What Would You Liike Me To Do?

An interesting shift; not as busy as I thought it might have been...

There is,as many of you will know, an ongoing struggle for us in the ED to convince our Specialist brethren that once in a while, we know what we're about.

I saw a young woman yesterday, with a long, complex history; the sort of history that makes life difficult for you - a mixture of physical and psychological, God-given and self afflicted. She has had many admits with belly-ache, and mostly managed with difficulty.

Yesterday she presented a week after taking a substantial overdose of tramadol, complaining of abdominal pain and an inability to open her bowels. So far, so constipation; except that her pan was uncontrollable (which may represent real pain, or simply a desire to obtain more morphine...) her pulse racing, and her lactate sky-high.

Her belly was tight, exquisitely tender, and I called for a surgical consult. The first surgeon I spoke to me told me he thought it all sounded "very soft". You can interpret that any ay you want, but I'm a stickler for tradition, and like my patients examined before their complaints are dismissed as "soft"

The next surgeon's input was limited to asking me what I was doing about the tachycardia?

Well, I've tried agressive fluids, enough morphine to kill a horse, and antibiotics in case she's perfed... I'm kind of stuck; so what I did was... call you.

Cometh The Hour

I have found this difficult to write about.

I suspect that we all, at one time or another have confronted our worst fears, either really, or in our minds. If you haven't you should.

It still might not be enough.

To me, an Emergency Physician is one who knowswhat needs doing, and how to get it done, in any given situation. Frankly, most of what we do, most of medicine, is not time critical... in as much as you can spend a few minutes mulling over your options.

The way I see it, my paycheck is the massive hoard it is because once in a while we don't have that luxury.

Imagine this.

Let us say a patient has been brought to you, having arrested out of hospital. They have survived, which is, in itself, a rareity. But they are now unmanageable, and need 'optimising'. In short they need their physiology dominated, by us, and controlled to maximise their eventual function. This will necessitate airway control; in this situation, there is a ittle time. The patient is maintaining an airway, and oxygenating and ventilating adequately, for now. It won't last. He will need intubation, and have to, effectively undergo a general anaesthetic.

You call for help from ITU, and go to talk to the family, update them and gain information. On hearing the phrase "general anaesthetic", the family immediately venture the fact that this patient has a difficult airway; you report this to your ITU colleague, and go back to the family. Having tidied things up at that end you return to your resus room, to find that the shit has hit the fan.

I had figured that we would wait until all the extra "difficult airway" kit was ready, and all hands were on deck, but somehow, matters had proceeded rapidly to a "can't intubate, can't ventilate" situation, in my absence.

For those of you not of a medical bent, this is my worst nightmare. Having paralysed a patient to pass a tube into their windpipe, you find you cannot pass the tube ("can't intubate") and moreover, you cannot force air into their lungs using a standard bag and mask combo ("can't ventilate".) In short, having stopped the patient breathing for themselves, you find you are unable to do it for them.

This is, I would argue, one of those time critical moments.

You should anticipate this sort of thing, prepare for it, be ready.

Walking in on it is not ideal.

Could you step up to the plate? Make the difference?

Taking Ones Eye Off The Ball

The targets we must labour under continue to insert themselves into out minds, insidiously, until we think they've always been there.

Where I currently work, there seems to be a strangely blase attitude to some of the stuff that comes in on the BatPhone, and I can't help but wonder if that's because we know they've got 'plenty of time'. Of course, they might die during that time, but, hey, at least they won't breach.

Maybe I'm wrong, and, of course, this is not the party line, but I keep finding patients in Resus, with no Doctor. Most recently was a fella found by his flat mate, unconscious. He was still unrousable on arrival at the ED, and went almost an hour before being formally assessed by a Doc. He ended up tubed and on ITU.

Now, maybe that's just me; no-one else seemed overly bothered, but I can't help but feel dudes in a coma ought to jump the queue...

The Needs Of The Few vs The Cost To The Many

One of the problems with trying to adopt an evidence based approach, to anything, but in particular, to medical testing and treatment, is that population studies do not tell individual stories.

The problem with using individual stories is that the plural of anecdote is not data, and association does not prove causation.

However....

A young middle-aged woman with chest pains present to the ED. They had woken her from sleep, but been transient, and she had gone back to sleep. In the morning she had something of a dull ache behind her breastbone, and felt a little short of breath. Simple remedies had not helped. Her pain had settled at time of exam, and she examined normally. An ECG was normal.

Past history, family history, all negative.

How to proceed?

She was admitted for observation and serial cardiac enzymes. Should she have had something else? A CT scan? CT coronary angiography? CT triple testing, looking at aortic root, pulmonary vessels and coronaries?

While waiting the result of her serial enzymes, she collapsed on the way to the toilet. Immediately after the collapse, she was alert, if slightly clammy, and her pain had returned. ECG now showed some T wave inversion, laterally, in keeping with an ischaemic picture.

Before she could be further assessed, her pain became excruciating, and she developed marked cyanosis, centrally. ECG continued to show ischaemic changes, but had not changed from the immediate post-collapse trace.

Within about 15 minutes, she became profoundly bradycardic, and then arrested. Prolonged resuscitation was, ultimately, unsuccessful.

I don't know what the PM showed.

PE?
Dissection?

If she had been investigated more invasively, might the outcome have been different? Maybe... maybe not. But most folks who present as she did, DON'T keel over. So if we scan everyone, won't most of them just have a normal scan, and increased radiation load?

So not scanning makes sense for the population in general... just not for her, I guess.

Sudden And Unexpected.

It's amazing how much better I feel having finished my exams. Conscious of the stress as I was, I'm still surprised to see how much better I feel, with them over. Of course, now I have to wait 3 weeks before learning of my fate,and possibly starting all over again.

Ah, well...

LBF has had to endure more than her fair share of deprivation, and I hope that now, we can spend more time making mischief. Although, of course, my rota may well continue to get in the way. She has been somewhat under the weather of late, but, having undergone emergent needling treatment, and something to do with balls in ears, is feeling more like her old self. Which, in case there was doubt, is witty and funny. (Almost always)

Anyway; the ED is often witness to the unexpected; as it should be, really. Almost by definition, emergencies ARE unexpected. Of courser, that's not always what brings folks to the ED, but there you go...

A young woman spent her evening getting drunk; I'm assuming that's what she did. To be fair, she might have been up to almost anything, but at the end of the day she was virtually insensible. An all too common problem reared its head - she ran out of, or could not find any, money. Her taxi driver called the Police, and they tried to intervene with her family, but they were unwelcoming. How many times must the have heard this call before? For they would not answer the call. Why?

We'll never know.

The Police had subsequently arranged for her to stop overnight in an Hostel, but by the time she reached it, she had grown cold and still. I suspect she choked on her own vomit, en route, but again, we'll never know.

Almost an hour of aggressive resuscitation did nothing to improve her countenance, nor restore her cardiac output.

To see the death of the young is always sad, and to see one that could so easily have been avoided, more so.

Maybe it's true, we pays our money, and we takes our choices, and the Devil take the hindmost.

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