Nights Part Two

In retrospect.

They were pretty decent actually; low volume, but occasionally complicated patients. Working with one of the Charge Nurses who spent the evening cheering himself in an understated manner... this is difficult to convey with the written word, but try to imagine an ironic cheer: a sort of sarcastic, sotto voce 'hurrah'... but for yourself.

Well I thought it was funny.

Maybe you had to be there.

Satisfaction came, as it so often does, in the form of two sickies. The first, in the late afternoon of life, with chest pain and an ECG that told all we needed to know, its ST segments sagging painfully in the anterior leads, dragging themselves up inferiorly. He was holding it together, just barely, his skin a grey sheen, his breathing ragged, and forced. I called Cardiology down, again, pushing more work their way. We're getting good at this shit now, buffing and polishing, prepping and turfing.

I take pride in being the ED Reg other registrars don't want to work with, the one who brings them work. (Not because they think I smell, I hope...)

The patient, in these situations, finds themselves immersed in vocal turbulence; the chat flows over them, sometimes turning to glance at them; rapid explanations duel with checklists being checked, bloods being drawn, phone calls being made. Mostly it's too much for them, they drift in ad out, an island in the middle of the rush to the balloon.

This one faded out a little too much; he just leaned back and ...stopped. The monitor quieted its annoying, monotonous beeping, and the display moved from regular, friendly complexes to an ugly mess; jagged, irregular lines. Cardiac rhythm by Picasso on acid.

VF.

A brief, very brief pause stretches out before us, as we all see it at the same time. These moments feel like stretching toffee... everything seems to slow down until they... snap, and we're back in the room, and it kicks off.

Praecordial thump, more in hope than anything does nothing, and the bed clatters down, damning any fingers too slow to get out. Sweaty hands begin forcing his chest down, one...two...three... to the tune of Nelly The Elephant, and the pads come out, electricity arcs through his chest cavity, and finds its mark. The monitor coughs, and splutters; when it recovers itself, the rhythm has normalised, and the patient's arms rise, rise ever so slowly, but rise to push us away.

Another of those elastic pauses... then **snap** he's back in the room, and the machine begins to turn again. Minutes later, the whirlwind has gone, blowing out of resus, leaving behind scattered syringe wrappers, dental rolls and ECG dots. ThromboNurse brings us his angio later, and we see his obtuse marginal artery, dammed with clag before, flowing freely after, and he's doing well.

A sotto voce hurrah doesn't quite echo through the Department.

The last, probably the worst. A young 'un, barely past the dawning of his day. Mum knows he's unwell, he's been off colour since last night but this morning has found his rash, and brought him to us.

I know he's not well; as they're ushered in, his skin is pale, sallow, with dark ugly circles under his eyes. His sits on Mum's lap, withdrawn, huddling into himself, but still bright enough to look about him. The history is quick to come out, and in between questions I'm asking staff to get me the tools of this particular trade: a cannula, blood bottles, fluid, antibiotics... we need his weight, but he's too weak to stand on the scales. I ask if mum will weigh herslef, then the two together, and she hesitates. I find this slightly absurd, in context, that her son is sick, and still she's worried about us seeing her weight.

I dismiss this as unworthy, she's terrified, she's not thinking straight, and we weigh him with me, instead. The cannula slides in, and he barely flinches. We've all seen the wretched rash by now, obscene reddish-purple blotches under his skin, the only colour left in him by now, and one none of us want.

Fluids and antibiotics follow the line in, and Paeds are down in a flash. My SHOs have watched in silence, not having seen this before, but recognising the gravity of the situation. We talk in hushed whispers afterwards, and I hope this means they never miss a sick kid, that this will serve to be their reference.

I leave him with the Paeds Intensivists, their presence both reassuring, and a stark reminder of how this disease is likely to pan out.

Calling PICU that night was hard to do, I'm not sure I want to hear the news, but he rallied they tell me, is well enough to be bored; he dodged to tube and hasn't needed inotropes. Mum brought him to us soon enough, and he's tough.

The 'hurrah' is a little less sotto voce

Let There Be Drums

So, actually, the last post had little to do with wishes, one way or t'other. This one does. Sort of.

Although, in unrelated news, I have decided the fictional doc I would most like to be is 'HawkEye' Pierce, as seem in M*A*S*H. But I'd most like to resemble the young Luca Kovac, from ER.

So... yesterday, I was workin a few extra hours, as penance for my record breaking oversleep. I owed 3, but asked to pay back 4, as a kind of debt of honour. It is always, always the little things that bite you.

As one a.m. rolled 'round (I should have finished at midnight), I was chatting shit with the SHOs, as is my wont. I heard the happy sound of a baby laughing; looking across the floor, I saw one of the sisters tickling a baby on a trolley in Bay Two.

In a split second everything changed. Almost in slow motion. In a film, or TV tie in, you'd see the smile fall off my face. The baby isn't laughing, he's choking, she's not tickling him, he's fitting.

As one, we're off, running across the floor, even as the call goes out - 'I need a doc here, NOW!'

He's a little one, 10 months, but chubby. A real cutey under different circumstances. He's hot, hot and clammy, and his whole body shakes, held in the grip of St Vitus' Dance. His parents, pushed to one side, are gibbering.

We have nothing paediatric out here... Sister and I support his tiny jaw, saturate him with oxygen as best we can; the adult mask looks ridiculous over his tiny face.

Soon, the carts arrive, someone hands me diazepam, in a little yellow dispenser. This stuff goes where the sun don't shine. No dignity now for the little fella; tho' in fairness it's difficult to maintain dignity when your 10 months old. Anyway, diazepam is in, and we switch to a better fitting mask. I can faintly hear his ma in the background: 'He's not breathing, oh, god, he's not breathing...'

The team is slick; I'm only vaguely aware of of them behind me, moving quickly, efficiently, handing me this venflon, that 'T-piece'. Now, blood bottles, now a saline flush.

Someone's with mum, explaining, reassuring; he is breathing, we are helping him, we're giving him drugs...

But, he's still fitting. iv access, a nightmare in chubby little ones... not this time; straight in, defying my shaking hands. Lorazepam, please. I revert to overly formal language, one of my foible.

'I'd be grateful if someone would do me the honour of passing me a miligram of lorazepam, at your convenience, please...'

Either way, it's there, as I ask for it.

In it goes, and now the monitoring is up and running. Other docs come and go, offering help, rubber-necking. The day has been quiet, now they all want a piece of the Shroom's circus. I'm not really aware of them. My mind is racing, trying to remember the algorhythm.

More lorazepam.

What's next? Paraldehyde? Paraldehyde. What's the dose? Do we even have it? Where do we keep it?

He'sbeen fitting for 20 minutes now. We're just about together enough to make the resus dash now; that's where the paraldehyde lives, after all.

Paeds have been called, but there's always something goin on, so it's us. It's always us.

We love it.

Paraldehyde is in, but he's still seizing, he's still hot. His airway is difficult to manage, but he takes an oral airway. This makes my life a bit easier, but doesn't say good things about his conscious level. Mum and Dad have finally had enough, and have stepped out, alone with their grief. I deploy a colleague to get the back story. I know nothing about this kid. Our entire relationship has been a fight between me, between us, and his febrile brain.

Next is phenytoin; my team have anticipated this, and 180 mg is drawn up, waiting. After that, we all know, is thiopentone; we aren't cut out for that, and the call goes out to PICU. As it's becoming apparent the paraldehyde ain't workin, Paeds enters stage left. God love him, he doesn't have any better ideas, and we start the phenytoin

Another line goes in, rectal paracetamol, and antibiotics, even before he can ask for it. Frankly, I'm still shitting myself, but my team are awesome.

Next onstage is PICU. The back story doesn't help, but the kid is sounding stridulous. This is high on the list of noises you don't want of hear when people are breathing.

The croup? Maybe.

I can still see thiopentone in all our futures.

But then...

As I'm holding his airway open, he reaches up, to push me away. He interrupts his tortured breathing to cry. I have rarely been so happy to see a grumpy frowning Winston Churchill look-a-like.

God love Phenytoin. He is coming around.

We sit him up, leave him to breath on his own. His airway no longer needs my sweaty grip. My focus begins to expand, and for the first time in an hour, I can see more than his little chubby face. My team swims into focus, and they're grinning. Like fools. I guess I am too. We're all pretty pleased with ourselves.

PICU is just as pleased. They always think we call them too early; we probably do. But I still see thiopentone in our future, and I like the company. Anyway, they fade to black, and leave Paeds centre stage.

As we all slip away, the chubby fella is sitting up, grizzling at us all. He's going to be ok.

He's going to be ok.

It ill becomes a man to brag, but we handled ourselves pretty well, considering we were caught with our shorts down to start with.

We can all feel good tonight.

Sad-Eyed Shroomy of the Lowlands

It seems most of what I write these days is apologies for not writing.
Sorry.

My mood has been lower than usual of late. Work, money, work, personal life... blahblahblah.
I'm still disappointed my life isn't quite ER. Ah, well...

This month has been PICU month. I'm due a 3 month Paeds secondment, but it hasn't been possible for me to do it all at once. So, I got a month. I haven't done any ITU for a while, least of all Paeds. So it's been a valuable experience, albeit perhaps not exactly what I thought.

Intensive care is an odd place; organised, controlled chaos, if you like. When I worked on adult ITU, I think it was then that the psychological trauma began to build up. Maybe. I found it very hard to see so many die. Especially the younger ones.

Now obviously in Paeds, they're all young. But it seems to me that few of them die. Which is nice.

Instead, what I have found challenging is watching the head injuries. The ones I've seen tend to be older - in their teens - and were usually on the wrong side of a moving car. They have non-operative CT scans - no large extra-dural haematomas to be hoiked out by my neurosurgical brethren. But their brains are tight.

Recovery is slow. Slower than I'll know, as I haven't seen the neuro-rehab ward. What I find frustrating is how non-specific we have to be to the parents. They'll probably survive, but we have no way of knowing how they'll survive.

It is the worst of things, and the best of things. I have never been more amazed by the strength of human spirit than I have watching the parents of these kids. I simply cannot imagine how it feels to have to come to hospital, day after day, and look at your son or daughter, previously so full of life, so vital, and look at them, pale and waxy, tiny in an adult's bed.
And keep smiling.

And once all the tubes are out - the ETT, the bolt, the EVD, the drips and all - they aren't better. They look around, blankly, their limbs flailing. Trapped in a body that won't obey them. And still mum and dad come in, holding the patient's hand, lying in bed with them, holding them tight. No parent banks on having to watch their adolescent be nursed in an adult nappy, on having to help bed-bath them. But they do it. I don't know where they find the strength.

And then... sometimes they just stop flailing, and start looking around. They start speaking. Their movements become appropriate. A 'high-five' has never meant so much to me...

Clearly, this is not the end; but maybe the end of the beginning? Or the beginning of the end? Something like that...

There really is hope. Who'd have thought?