Voila Le Morse!

So, I'm lagging again. About a week behind. Good intentions trailing in my wake.



The problem is, the longer you leave it, the blurrier the edges get.



Last weekend (10 days ago now) wasn't so bad; along with the pressure of the trial period comes extra staff - which, shock/horror, moves things along a bit quicker - so a bit less for me... Saturday was tough; One of my favourite sisters was on... but she is a wee bit 'black smoke'. Her first words to me were: "It's not looking too bad..."



10 minutes later, and resus is humming. Contestant number one has complete heart block, and is not at home to external pacing. Actually, we did get capture very briefly, but then our new all singing, all dancing defibs gave it up.

I'm not sure I trust them. They talk to you, in a kind of mid-Atlantic accent, beloved of 80s DJs, or airline pilots. What they say wouldn't be amiss as porn dialogue (e.g "Harder! Faster! No, that's too fast... go slower, and deeper" They are of course referring to one's compression speed and dept, but...)

My other concern is that they'll turn out like HAL, from 2001. So:

Me: "Charge to 150!"
Defib: "I can't do that, Dave..."
Me: "What? Why not? And why are you calling me Dave?"
Defib: "I'm sorry, Dave, I can't tell you that"
Me: "Right! Where's the manual button..."
Defib: "Dave. What are you doing, Dave? Don't do tha..."

Anyway, his potassium is stratospheric, which clearly ain't helping, and made us look like hicks, when it took CardioReg to point it out... He won a trip to the lab for pacing wiring, and a brief, unfulfilling discussion between medicine and cardiology about who should look after him.

Contestant number two has fallen too high and broken most of her vertebrae; she's a hand-over, but ortho and neuro are arguing over who gets to do less work; neuro invariably win, and the Ortho Reg, a buddy o mine is grumbling about still clerking patients at his time of life. I feel the same, and wonder briefly where all the house officers went.

Contestant number three has tried hanging himself, and is GCS 3: flat and hurting. He arrives as I'm trying to stabilise Contestant number one. Just as I think I might be able to manage them both - if I run back and forth quick enough - number one's hear pauses long enough for Sister to demonstrate the art of percussion pacing. She ascends to the pantheon as my new hero. Patient isn't quite so thankful, but then all he knows is being forced awake, from the ultimate sleep, by a punch on the chest.



Squeaky bum time, so to speak.



We somehow find a way through; we always do. All my patients leave the department alive; sometimes that's the best I can say. I'm embarrassed to say, I don't know how they are now. Another girl falls from a window; suicide attempt? I'm not sure... she surely wasn't keen on the pain when she got to us. I find these cases the hardest. The physical hurt can be treated, can be rationalised... the mental pain? I don't know. But we seem to see an awful lot of people who thought they wanted to die, and only ended up adding physical pain to their already overloaded psyche.



The winner of the night is a psychotic fella. It is debatable as to whether his mental state was drug induced; indeed, I have debated it for more hours than I care to remember. What I do know is that he had dedicated the previous three days to smoking cannabis, and then something deep inside went 'boing'.



He was unmanageable; sometimes a body can reason with the truly raving. Not this guy.

He was just shouting, incessant, illogical demands. Sometimes for cannabis, sometimes for incongruous luxuries - a massive tv, a PS3. Sometimes he shouted his fears at us - that everything was black, that he was a Government experiment, a freak. Where were all the other freaks?, he wanted to know, why could he not meet them.

And yet, every now and then, for a few seconds, sanity appeared to return. 'Help me', he would implore, 'please..'

I sedated him.

Rapid tranq. A sledgehammer approach, perhaps but safe, and allowing me to assess him. In the end, we had to have him removed by the Police, for formal forensic assessment. His Grandmother and Father, so relieved that he was finally in hospital, struggled to understand why it had to come to this. My words seemed woefully inadequate, even to me, trying to explain that a police cell was safest for all, until the psychs could see him.

Actually, it became a moot point hen he biffed a copper in the face, but the principle was there.

I don't know what happened to him, either.

Sometimes, I lie awake at night, and worry that theses are the ghosts that will haunt me for ever.

Weekends Are Fun. Right? (3)

I'm actually a bit written out on this now.


Sunday was proper shit. I left the department in a state, and it never recovered. Playing catch up was impossible. So, it was an unhappy return for me on Sunday night.


Once again, my evening was dominated by Resus. This evening's specials were the very breathless. I find it odd how cases seem to come in a run. I guess it's because we only remember the runs. When 3 breathless punters come in one after t'other, it sticks. 3 different cases doesn't seem such a big deal.


I got some lessons in assertiveness from the duty Surgical Reg. (Who else...) Its all about language. Our patient is an elderly chap, brought in when his wife found him collapsed, and unresponsive in bed. He had been fine earlier in the evening, but complained of a bit of pain in his hip, and retired to bed. The ambos had just confirmed his flat GCS and scooped and run.



At first, I was at a bit of a loss, but his BP of 50 systolic shed some light on his incapacitation. As did the presence of a firm, pulsatile, expansile abdominal mass. ED USS showed an aneurysmal aorta, with fluid in Rutherford Morrison's pouch.



Says I to the surgeon: Think this fella has a ruptured AAA...

Says the surgeon to me: He's got a AAA

Says I to he: That's what I said!

He to I: No; you said you thought he had.

Me: Ah, sorry. I was trying to be polite...

I guess I always say 'I think' before offering a diagnosis. But for me, 'I think' often means 'I'm sure'. Guess I should just say what I mean.

Anyway, an aneurysm it was, but not one amenable to surgery. Another night, another family whose hopes I've dashed.

All that's left is an attempt to find quiet dignity. We just about managed. It's hard to do in the ED. More of this to follow. Right now, I just wanna finish exorcise this weekend.

Weekends Are Fun. Right? (2a)

More Saturday; I'm beginning to think this weekend isn't worth the telling. It's harder to write than it was to do. Well, I've started anyway...

While car crash fella was under the knife, our attention was diverted by car crash gal, and another trauma that BASICs seemed to have smuggled into Majors. I'm sure they didn't do it deliberately, but 'twas a while before I found them.

Car crash gal, was the passenger in the same wreck that gave us the fella on the operating theatre. One of my SHOs ran the rule over her. My eyeball of the patient had suggested she was a bit more stable that the guy, but still...

Sure enough, although her numbers were all in the right place, and stable, she had considerable bellyache, and was developing a bit of rigidity. There followed a slightly confusing conversation with my colleague on call for radiology. What I wanted was a CT head and abdo. It seems that we scan all or nothin' here, so was I sure that's what I wanted. My SHO had been a bit 'uncertain' about the physical findings on the phone. My big beef with radiology is this. They have fixed criteria for what they'll scan. Fair enough, they are the guardians of ionising radiation, which is not a toy. But, without seeing the patient, I don't see how you can say they aren't tender enough to warrant a scan. Or, because their numbers are normal, they don't need one...

So one has to be fairly definite about what the problem is; it's the least they deserve.

Reluctantly, she went through the scanner.

Which showed free air aplenty... (For those uncertain, this is not a good deal. It's not like free chocolate. You don't want anything free in your belly, really...)

Another for the surgical conveyor belt; it transpired she had a few holes in her small bowel, which is a not uncommon result of a deceleration injury. More evidence that people lie and cheat, even when they ain't trying. This wee lassie had significantly more serious injuries, but you'd never have known it to look at her...

That must be it, right?

No.

The trauma smuggled in turned out to have an unstable lumbar spine fracture, but thankfully no cord injury, and our night was completed by a six a.m blue call to an unstable MI. Chest pain, with fat ST elevation, uncontrolled hypertension, and profound hypoxia...

I'd like to say I was cool under pressure and successfully treated all of his problems, systematically, and thoroughly.

It didn't quite work out that way.

God Bless Cardiologists.

Weekends Are Fun. Right? (2)

And so to Saturday.

It can't be any worse, right. Not worse, maybe, but just as bad in a different way.

The Dept was as busy, if not more so. I think the second board was out on arrival. (This means there were so many patients in the department, that we'd run out of space on the regular board. It is not a good sign)

Again, the details are beginning to escape me. I'm not sure if my memory was always this shaky. I can't remember.

A heaving department, but resus call after resus call. Once again the department becomes crystallised into this small room. Outside I know we're up shit creek without a paddle, but I can't do anything about it. I can't get out of here, they won't stop coming.

Tonight's featured cases are trauma, again.

First up an RTC. High speed, head on collision. Two victims. The driver was the subject of a prolonged extrication; a BASICs doc was on scene and asked for a surgeon to be waiting. The BASICs guys, and gals, are pre-hospital docs, working in their own time. They embody the spirit of the orange jumpsuit.

Anyway - we had a fifteen minute heads up, but that didn't translate well to the duty surgeon, who was crash bleeped to resus, and slightly nonplussed on his arrival. Eventually the patient rolled in. His entrapped state had required ketamine on scene. This is a 'battlefield anaesthetic'. Can be given intramuscularly, and produces analgaesia and dissociative anasthaesia. There is an occasional view among the ED regs that the BASICs guys are a bit too liberal with it.

So, the guy is boarded and collared. His airway seems ok, but I'd better check.

--'Sir?, Sir? Can you tell me your name?'

He opened his eyes, very slowly, looked me dead in the eye, and said:

'Wow!' (I'd like you to imagine this being spread out over about five seconds. That gives you the idea)

I guess there's something in this drug being used illicitly.

Primary survey revealed a tender abdomen and pelvis, with hypotension, transiently responsive to fluids. Chest X Ray showed pulmonary contusion, with possible haemothorax, and FAST scan was negative.

As per usual, my knife wielding colleagues wanted a CT scan, but the patient's blood pressure intervened, and straight to theatre he went.

One ExLap later, and all that could be found was significant retro-peritoneal bleeding. He continued to behave in a labile fashion, and I can't help but wonder if there was some other injury, but haven't heard yet. More or less a tick in the positive box; ah, but the night was yet young...

Weekends Are Fun. Right? (1a)

And so it went on...

While keeping an eye on some poor fella who'd been stabbed in the belly - We guessed he wasn't too bad when he began devoting his time to feeling up the nurses - I was chatting to one of the local Constabulary. I think they were all in the ED at some point that evening. Anyway, their little shoulder radios are always going off; they sound a little like the teacher from Charlie Brown to me. You can never quite hear what the jazz is.

Anyway... this time, the radio goes off, the copper listens intently for a while then looks over at me. I raise an eyebrow, quizzically. (In my mind...)

More squawking chatter; another glance.

What?

Rueful smile. 'More business for you, Doc...'

What?!?

Shake of the head. 'Doesn't sound good...'

WHAT?!

'Another stabbing. In the neck. They're not sure if he'll do'

I look around the rest of the Dept. Minors and Majors are both heaving. I can't remember what the wait was by this stage, but I'm guessing it was over 6 hours to be seen. Ambos were already queueing...

Sure enough, a few minutes later the call came. Young man, multiple stab wounds, suspended. I remember the first time I took a call like that, I couldn't figure out why everyone was so excited, or why someone would be suspended.

From what? Eh? Oh.... that's what it means...

How times change.

The next few hours were very ER.

The details blur around me, faster and faster as the days go by. I remember his colour, a pale, waxy yellow. It's never good, but you don't need me to tell you that. His chest laid bare, the wounds on his chest so small, so innocuous looking. So little blood.

That didn't last.

Part of you knows there's no hope. But most of you doesn't want to believe it; and you want to try. He's so fucking young. The worst part of you feeds on the adrenaline, and wants to act because it's cool. It's exciting. It feeds the beast.

As ever, telling the family was the worst. They look you in the eye, and plead: 'Why can't you fix him. Do something, fix him, make him better...' The despair tailing off as the brutal reality slowly sinks home; oh, so slowly.

You could stick a fork in me after that. I was done.

Does it count for anything? Does it tally somewhere that we all tried as hard as we could, flying in the face of a lost cause.

I'm not sure. The only tangible results will be a blip in the waiting time for those hours when we tried. Will a time come when I see this case and call a halt straight away, when I admit the hopelessness, and devote myself to the big picture?

I don't know.

Weekends Are Fun. Right? (1)

Friday Night.

Actually, I like working nights. More autonomy, and it feels vaguely romantic to me. It's ok, I have insight. I know this is weird, but I can't help it. There's something about hospitals at night...

The Department is busy when I come on. Not the best sign, but it's do-able. The waiting room is bristling as usual. The world's most aggressive goldfish bowl.

I have resolved to try and let the SHOs run resus tonight. It doesn't quite work out that way.

Resus is packed when I come on. In bay one is a patient waiting to go to the ward. Some have been waiting 9 hours for this privilege. I think she's got a broken femur, and assorted other fractures. In two is wheezy, short of breath. Also waiting on the ward. I forget who was in three.

This strikes me as terrible. It was less than a week go, and already I have forgotten so much. I think maybe it was a kiddie.

A few simple resus cases flow in. Then it starts to clog. At one stage we have 5 acute cases in a 3 bedded resus.

Then the first of the big three:
Young-ish. Attempted hanging. Head injury on being cut down. Agitated.

When he arrives, my worst fears are not confirmed. His airway is patent. No laryngeal fracture that I can appreciate, and although he looks congested in the upper half, I can feel no sub-q emphysema.

(This is air within the skin. It feels a little like Rice Krispies, or bubble wrap. It is indicative of air leaking into the tissue, usually from the lungs. It is high on Shroom's list of Ways I do Not Want My Skin To Feel.)

He is agitated tho'. And de-cerebrating - an abnormal extensor posturing of the limbs. This is, of course, high on Shroom's list of Postures You'd Rather You Weren't Exhibiting.

He has an ugly wound on the back of his head; evidence of where he was dropped. The final indignity, if you will. Cruelty, heaped upon cruelty.

While trying to restrain him safely, we get to play the ED sedation roundabout / roller coaster game. Up and down, round and round she goes... where she stops, nobody knows. Fortunately, I'm a veteran of this game, and we stop just where we need to. Help arrives in the form of a friendly gas-passer, and we send our guy away to a better place. This, at least affords me the opportunity to come over all ER by straddling the trolley to provide manual in-line stabilisation from the bottom end.

The long, dark walk to the scanner, while I make a few unwelcome phone calls, and break a few hearts in the relatives room. I do not feel a better person.

The scans all come back negative, which is only slightly reassuring. Anoxic brain injury can be like the wife-beater's kidney punch, ruining lives without leaving a mark. That will come later.

There briefly follows a surreal period where I and my anaesthetic colleague try to arrange admission for our guy. Ortho and Neurosurg all agree he will need their input; just not right now, so they aren't admitting him. I am disappointed to discover this doesn't really surprise me.

After a brief hair tearing, my Maiden in Shining Armour (she of the Expensive Scares) convinces the Magicians that they should take the patient.

I can't pretend to understand it, but at least we found him a nice warm vent for the night.