Back, at least for a while. I had intended to wait a day or two, to refit my life all at once; but this idea came to me, and I felt i ought to write it before I lost my mojo again.
I am become a creature of the twilight; lates and nights stalk my rota, and I've forgotten what a normal day looks like. I'm sitting among the detritus of my life that late shifts bring, drinking rum, if that helps.
Sometimes, I feel like we make a difference; sometimes I'm sure we don't. But I guess we try anyway.
The first comes early; or late, depending on which end you're starting from. The shift is a swap, and horror often seeks you out on a swap. Whatever Gods look down ensure that no good deed shall go unpunished. Actually, the shift had been fine. I'd been cloistered in Paeds and Minors all night, my most challenging case a complex nail bed injury; some poor fella's thumb transformed into an horror of pulp. I spend an indecent amount of time trying to put it back together before admitting defeat and sending him to see Plastics.
I look up, and it's seven in the morning. The department is pretty quiet, and I allow myself the thought that I might get away on time.
The phone rings, and the shrill tones gently nudge my adrenals. The sound of that ring is embedded in my cortex, somewhere, along with crash bleeps I have known, all of which still exert a Pavlovian pull on me.
Enough. The story is bad, telling a tale of a young patient hit by a van, not breathing. I have to push selfish thoughts, the knowledge that I'll be late away out of my mind.
We wait. The department seems to take a breath, and hold.... on.....
Then the Ambos arrive, and it's let out in a gasp. Our patient isn't breathing either, and not tubed - the crew are double tech, and no doc able to attend. We lift him over, and I see his colour for the first time, pale and waxy. It is the absence of colour, that in my experience means all his blood has left the building, so to speak. It is always a bad colour, and in trauma, and in the young, spells disaster.
He is not breathing, and we call for the Intensivist.
10 seconds later, it is worse; his heart is not beating. The ECG monitor glares at us, the flat line telling me what I already know. He's bled out, his heart empty.
Blunt trauma, cardiac arrest. Only his youth stands on his side; but I know it won't be enough.
I struggle, briefly, with the tube. Not long enough to make a difference to him, but enough to unsettle me; when the Intensivist arrives, i stumble over my words; this has gone runny really quickly, and I am, as ever lucky to work with a cool, efficient team.
I decompress both chests, to prove the lungs are up, hunting for blood, not finding any. We drill into his shins, cut into his groins, filling him full of blood cold from the fridge. His pelvis and thighs feel stable, and I still can't find his blood. We slide a needle into the thin sac around his heart, and tap 10 mls or so out. SonoSite tells me there's no more there, and that his belly is full of fluid, in this context, the blood I've been searching for.
I look around; an hour has passed, and we've replaced his volume, pumped his chest, pumped his lungs.
It has done no good.
We all know it. I ask for dissenting opinions, and there are none. We make eye contact, one last time, a gentle shake of the head. My day is done now, and I won't be able to see his family, to tell them how hard we worked, how hard we tried. I leave the department unable to meet anyone's gaze.
The next day; the same phone. An elderly patient, bellyache and low blood pressure. The ?aneurysm. During the day, the Department is that much busier, the waiting isn't the same. At night, you may become the focus for h whole department, everyone coming to help, or at least rubberneck. On a day like today, everyone has enough to be going on with, and the only breath holding is done by me.
He arrives, awake and groaning. We lift him gently over, and I see his colour for the first time, pale and waxy. At least he's still talking to me. The Ambos belt out the history, of an hypertensive, elderly patient, 2 day history of worsening abdominal pain, now going to his back and groin. They couldn't feel an aneurysm, but the history and the pale, sweaty patient in front of them meant they didn't need to.
I feel it right away. It's big; too big, I suspect for the Paramedic to have found it; but, to be fair, the Surgeon, who arrives within seconds, is also skeptical. The SonoSite, showing a seven cm mass convinces him. Big lines, a trickle of fluid and some morphine kit our fella up, and we run to theatre. I love theatres out of hours; long corridors, deserted, with odd trolleys stacked neatly, promising work to come. We deliver our patient, and I'm pleased to see how quickly everyone else gets going. Surgeons, Gasmen, Intensivists. I miss this life.
As we leave, I look at the clock. 30 minutes have passed since he hit the trolley downstairs. I don't know whether I should feel proud of this fact, but I do. My good mood is improved immeasurably when one of the nurses skids on a wet floor while trying to open the door to resus. I should add, she didn't fall, or hurt herself, but the effect was hilarious. After she's skated past me, I look at the floor of resus; I'm struck by how similar success and failure are in what they leave behind.
Before I leave, word comes down that he made it out the other side, and there's a little spring in my step as I leave.
Showing posts with label Trauma. Show all posts
Showing posts with label Trauma. Show all posts
Friday, November 14, 2008
Thursday, June 26, 2008
On Top, Doggy And Normal
A Tale Of Three...
You came first; reluctant, disgruntled. A familiar ale, of a rough struggle in the night, steel toe-capped boots leaving their angry retort. A litany of complaints, of your head, your neck, your chest and your shakes. We saw you immediately. You argued with us then, unhappy at your confinement, unwilling to see the necessity... we explained, cajoled. You swore and threatened. We hoped it was your head injury... it was just you. We cleared your neck, offered pain relief, albeit not the opiates you wanted, eased your shakes. It wasn't enough. We were too slow to bring you the coffee and sandwiches you wanted. You told us you couldn't walk, couldn't see, couldn't turn your head. But when no food was forthcoming, you got up, looked around, offered one final charming epithet and walked out. In a straight line.
You came second; the pain you were told was gallstones finally peaking until you couldn't bear it no more. They found you on the floor, pale, clammy, groggy. Two minutes later, you were on our trolley; the scanner showing what we all knew was there, huge, obscene, spilling warm claret into your already swollen belly. 5 minutes later and the knifeman (actually a knifewoman in this case) is by your side. We've roughly violated every vein we can find, and the fluid has stopped the incessant drip of sweat, calmed your pulse to the low hundreds; you can think again, in time to absorb the dreadful news the surgeon carries; five minutes later, you're in theatre. I know you came through this most dreadful of ordeals, and maybe, in some way we helped. I'll look for you again today.
You came last; spinning off your bike in the lengthening darkness; the resentful ground bending you so cruelly to fit its purpose. We were on scene almost immediately, but it did no good. Cool plastic pushed air into your lungs, but the slowly cooling egress from the holes we made in your chest spoke of a darker outcome. The truth was starkly illuminated by our unforgiving fluorescents. The gaping rent in your thigh, as obscenely neat as any dissection I ever did, lay perfectly dry, an un-natural state in the living. An so we allowed you to pass on, eyeing each other with grim familiarity. A slow shake of the head, the turning away... all that's left is the meeting on the ledge.
Perhaps we all drove home a little slower tonight.
You came first; reluctant, disgruntled. A familiar ale, of a rough struggle in the night, steel toe-capped boots leaving their angry retort. A litany of complaints, of your head, your neck, your chest and your shakes. We saw you immediately. You argued with us then, unhappy at your confinement, unwilling to see the necessity... we explained, cajoled. You swore and threatened. We hoped it was your head injury... it was just you. We cleared your neck, offered pain relief, albeit not the opiates you wanted, eased your shakes. It wasn't enough. We were too slow to bring you the coffee and sandwiches you wanted. You told us you couldn't walk, couldn't see, couldn't turn your head. But when no food was forthcoming, you got up, looked around, offered one final charming epithet and walked out. In a straight line.
You came second; the pain you were told was gallstones finally peaking until you couldn't bear it no more. They found you on the floor, pale, clammy, groggy. Two minutes later, you were on our trolley; the scanner showing what we all knew was there, huge, obscene, spilling warm claret into your already swollen belly. 5 minutes later and the knifeman (actually a knifewoman in this case) is by your side. We've roughly violated every vein we can find, and the fluid has stopped the incessant drip of sweat, calmed your pulse to the low hundreds; you can think again, in time to absorb the dreadful news the surgeon carries; five minutes later, you're in theatre. I know you came through this most dreadful of ordeals, and maybe, in some way we helped. I'll look for you again today.
You came last; spinning off your bike in the lengthening darkness; the resentful ground bending you so cruelly to fit its purpose. We were on scene almost immediately, but it did no good. Cool plastic pushed air into your lungs, but the slowly cooling egress from the holes we made in your chest spoke of a darker outcome. The truth was starkly illuminated by our unforgiving fluorescents. The gaping rent in your thigh, as obscenely neat as any dissection I ever did, lay perfectly dry, an un-natural state in the living. An so we allowed you to pass on, eyeing each other with grim familiarity. A slow shake of the head, the turning away... all that's left is the meeting on the ledge.
Perhaps we all drove home a little slower tonight.
Wednesday, April 02, 2008
Can't Find My Way Home
I have a bad taste in my mouth this eve; and not simply because I slept badly, and snored.
Good things continue to brew in the background for the Shroom, but it continues as a work in progress, so... shhh...
As a Doctor, part of the deal, maybe most of the deal, maybe ALL of the deal is being the patient's advocate. With all the privilege it entails, patients expect, deserve, demand that we do our best for them; that we do our best, even when others disagree with us.
And this morning I failed my patient; I missed what would turn out to be the crucial detail in her history, although I did not fail to see how ill she was. But I was unable to convince my colleagues of this fact; allowed myself to be pushed around; I could not convince myself to step up for her and force others to help me treat her.
I find this incredibly frustrating; especially when, as this case did, a patient straddles the day / night boundary. With the dawning of the day, the Hospital stirs itself to life, and suddenly everyone is interested in your case, and mostly in criticising your management thereof.
I'm not sure the delay will affect outcome; but I was stung to the quick, having spent 2 hours trying to attract speciality assistance, to have them phone me and 'pass comment' on the delay I was causing.
Sometimes, I hate my job.
For the record, the case was, I suspect, Boerhaave's Syndrome. The patient presented with abdominal pain, following vomiting. Radiograph showed a pneumothorax, possibly pneumomediastinum, and loculated effusion in the left chest, producing a degree of mediastinal shift.
Good things continue to brew in the background for the Shroom, but it continues as a work in progress, so... shhh...
As a Doctor, part of the deal, maybe most of the deal, maybe ALL of the deal is being the patient's advocate. With all the privilege it entails, patients expect, deserve, demand that we do our best for them; that we do our best, even when others disagree with us.
And this morning I failed my patient; I missed what would turn out to be the crucial detail in her history, although I did not fail to see how ill she was. But I was unable to convince my colleagues of this fact; allowed myself to be pushed around; I could not convince myself to step up for her and force others to help me treat her.
I find this incredibly frustrating; especially when, as this case did, a patient straddles the day / night boundary. With the dawning of the day, the Hospital stirs itself to life, and suddenly everyone is interested in your case, and mostly in criticising your management thereof.
I'm not sure the delay will affect outcome; but I was stung to the quick, having spent 2 hours trying to attract speciality assistance, to have them phone me and 'pass comment' on the delay I was causing.
Sometimes, I hate my job.
For the record, the case was, I suspect, Boerhaave's Syndrome. The patient presented with abdominal pain, following vomiting. Radiograph showed a pneumothorax, possibly pneumomediastinum, and loculated effusion in the left chest, producing a degree of mediastinal shift.
I never cease to be amazed how quickly my colleagues disavow themselves of potential responsibility; all hail Specialisation.
I promised her husband we'd get to the bottom of it, and see her right. I couldn't look him in the face on my way out.
Tuesday, March 25, 2008
Little Wing
Where once there used to be an 0600 Cardiac Call, I now seem to attract an 0755 squeaker. This one came with a warning. The BatPhone trills us out of Monday morning's quiet reverie. It had been peaceful for a few hours. I even lay down for half an hour.
I should have known better. Superstition dictates that the Shroom who is planning a quick getaway brings ruin on himself; and the poor bugger that ends up in the ED, of course.
Control is calm; matter of fact. They always are. Car smash, sounds high velocity. Three casualties - two kids.
Enter the squeakers.
They arrive piecemeal, not in the order we were told. A 10 year old first - she looks well, and I deploy SHO Kingsmen.
We wait. Not for long. He's right behind, made smaller by the board. He looks tiny surrounded by the Techs and Paramedics; dwarfed by the monitors.
He's very quiet.
This makes me nervous; the quiet ones make me nervous. This fact is generally lost on adults, who generally believe that by shouting good and loud, they'll get dealt with quicker. It just tells me they have a patent airway, and breath enough to shout, and energy enough to waste doing it.
But the quiet ones...
A quick eyeball reassures me. He's alert, engaging his surroundings. I remember his eyes as piercing blue, but maybe that's dramatic licence. His view is limited by the sandbags stabilising his neck. The traditional ED view - nothing but ceiling tiles - and now me. He locks on as my face hoves into view. I try to think of something to say that will make this all alright for a 4 year old.
He looks less than impressed, but doesn't struggle as I clamp my hands and forearms to his head. A soft tissue vice, if you will. We run the primary survey ruler over him, and he comes up clean.
By know his sister has spilled the beans. L'il fella speaks no English. They were in a car hit at speed from behind, and rolled. Big sis crawled in to pinch him from his car-seat. My respect for both of them grows, enormously. I keep talking to him, aware now that tone is more important than words. He fixes me with his steely gaze once more; all the acknowledgement he can manage, he goes back to studying the ceiling.
Finally in a well fitting collar, we roll him; still no sign of injury, but we have to have his sister translate the indignity visited upon him. When I ask him to clench his buttocks, he does so with vigour. I half expect him to yell "Ta-Daa!" to accompany the demo of neuro-muscular integrity. (Which is the purpose of said request, in case the non-medicos were just thinking I was warped...)
He doesn't flinch as we cannulate him, draw his blood into tiny vials, virulently red against his pallor. I try to cheer him by making one of our Masonic teddy bears put on a little song and dance. He treats the display with the contempt it deserves. Everyone a critic...
By now I'm ready to hand over; pass his care like a baton; he is stable, needing some X-rays, but I feel he'll be OK. By now, his Mum has arrived. We MacGyver the trolleys next to one another, so L'il Fella can hear and touch his sis and Ma, even if he can't see 'em yet.
When he hears Ma, he breaks his silence, and a stream of language pours forth; the words spill into the resus bay, silent with relief that no-one appears seriously hurt. We've all seen the pics of the car the Paramedics brought in on their phones. Whether we like it or not, these images bring a flash of what could have been - the tearing asunder of the fragile forms before us.
With Ma nearby, and his voice rediscovered, it is finally too much for him, and he breaks; just a little at first, then rapidly, as his face crumples under the weight of what has happened to him. Finally he gets a little colour in his cheeks as he struggles to stem the flow from his bright blue eyes.
As I turn to leave, I have to cuff at my own eyes, just a little. Must be dusty in here...
I should have known better. Superstition dictates that the Shroom who is planning a quick getaway brings ruin on himself; and the poor bugger that ends up in the ED, of course.
Control is calm; matter of fact. They always are. Car smash, sounds high velocity. Three casualties - two kids.
Enter the squeakers.
They arrive piecemeal, not in the order we were told. A 10 year old first - she looks well, and I deploy SHO Kingsmen.
We wait. Not for long. He's right behind, made smaller by the board. He looks tiny surrounded by the Techs and Paramedics; dwarfed by the monitors.
He's very quiet.
This makes me nervous; the quiet ones make me nervous. This fact is generally lost on adults, who generally believe that by shouting good and loud, they'll get dealt with quicker. It just tells me they have a patent airway, and breath enough to shout, and energy enough to waste doing it.
But the quiet ones...
A quick eyeball reassures me. He's alert, engaging his surroundings. I remember his eyes as piercing blue, but maybe that's dramatic licence. His view is limited by the sandbags stabilising his neck. The traditional ED view - nothing but ceiling tiles - and now me. He locks on as my face hoves into view. I try to think of something to say that will make this all alright for a 4 year old.
He looks less than impressed, but doesn't struggle as I clamp my hands and forearms to his head. A soft tissue vice, if you will. We run the primary survey ruler over him, and he comes up clean.
By know his sister has spilled the beans. L'il fella speaks no English. They were in a car hit at speed from behind, and rolled. Big sis crawled in to pinch him from his car-seat. My respect for both of them grows, enormously. I keep talking to him, aware now that tone is more important than words. He fixes me with his steely gaze once more; all the acknowledgement he can manage, he goes back to studying the ceiling.
Finally in a well fitting collar, we roll him; still no sign of injury, but we have to have his sister translate the indignity visited upon him. When I ask him to clench his buttocks, he does so with vigour. I half expect him to yell "Ta-Daa!" to accompany the demo of neuro-muscular integrity. (Which is the purpose of said request, in case the non-medicos were just thinking I was warped...)
He doesn't flinch as we cannulate him, draw his blood into tiny vials, virulently red against his pallor. I try to cheer him by making one of our Masonic teddy bears put on a little song and dance. He treats the display with the contempt it deserves. Everyone a critic...
By now I'm ready to hand over; pass his care like a baton; he is stable, needing some X-rays, but I feel he'll be OK. By now, his Mum has arrived. We MacGyver the trolleys next to one another, so L'il Fella can hear and touch his sis and Ma, even if he can't see 'em yet.
When he hears Ma, he breaks his silence, and a stream of language pours forth; the words spill into the resus bay, silent with relief that no-one appears seriously hurt. We've all seen the pics of the car the Paramedics brought in on their phones. Whether we like it or not, these images bring a flash of what could have been - the tearing asunder of the fragile forms before us.
With Ma nearby, and his voice rediscovered, it is finally too much for him, and he breaks; just a little at first, then rapidly, as his face crumples under the weight of what has happened to him. Finally he gets a little colour in his cheeks as he struggles to stem the flow from his bright blue eyes.
As I turn to leave, I have to cuff at my own eyes, just a little. Must be dusty in here...
Monday, March 17, 2008
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:
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.
My mouth has run dry. The non-medical jib will wait.
Happy St Patrick's Day tae ye all.
Slainte
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
Monday, December 24, 2007
Hey, Hey LBJ, Ruin Christmas For Me Today
Clearly, for LBJ, read Shroom; but that don't rhyme.
Last two shifts have been hellish. Busy, busy, busy, punctuated by flail and trauma.
A patient bought beer for the ED staff, however, and I intend to finish my shift drinking one in the Ambulance Bay. Merry Shrooming Christmas.
Tonight, my last for a few days, was eerily quiet. Quite nice, actually; but a quiet department makes me nervous. It's superstition, I know, but I also know it means something shit is waiting.
Tonight was no exception.
Having begun to think that we might make it through, actually having an entire shift that was nice and quiet, the BatPhone trilled into life. While this usually means someone unwell, we do get a variety of stuff phoned through. If you're dying, you'll come through on the phone, but if you come through on the phone, you ain't necessarily dying.
First, a cardiac arrest. I'm embarrassed to say that I can't remember how old he was, even though he slipped away from us less than an hour ago. 70s, I think. The crew that brought him had been going an hour, with no encouraging signs. There's really no comeback once you've been dancing with the Angels that long, but we'll try. The team is ready, and eager; callous though it may sound, it's also a good opportunity for the juniors to try their hands at running an arrest.
Another 30 minutes with us and we were finally ready to accept what we all knew was true. So my SHO got to learn the art of breaking bad news; this time of year it seems especially cruel.
As we were getting our breath back, the unwelcome trilling rang out again. Another gent, 70s again; bellyache, low blood pressure, poorly responsive. Time only to wipe our brows and breath in.
When he arrives, I can see he's in trouble. A raven might as well have been perched on his shoulder. He had apparently gone off as soon as the Ambos arrived, slipping into unconsciousness, and abandoning all attempts at breathing. His pulse, fluttering, weak, thready; barely evidence of a tenuous hold on life.
It didn't last.
Within minutes, he was gone. We were still gathering obs, still trying to make sense of the puzzle before us when he lost his fight. CPR started immediately, and I tubed him; slick as you like - Grade 1 view, some airway soiling, but the semi rigid, impersonal endotracheal tube whipped between his cords as easy as you like. Forcing air into him desperately, I couldn't tear my eyes off his belly, which was blowing up in front of our eyes.
For a few frantic, soul searching moments my 'satisfaction' with the tube turned to self doubt.
'It's in his fucking oesophagus...'
Then the CO2 monitor lit up. CO2 only comes from the lungs, so the tube couldn't be anywhere else. I think that might be called 'cold comfort'.
Another undignified struggle. Nothing made any difference; every intervention a small victory, but in a losing campaign. As is so often the case, all the cajoling, all the pleading in the world, couldn't get his heart started.
My turn to talk to the family. The usual explanations; the apologetic, quietly spoken words. I don't know how they hear them, but they echo dully in my own head.
And finally, they take it in, for now anyway - tomorrow will be different, and the next day, until the realisation finally takes root - and they thank me.
'For all you did for him'
For ruining Christmas
Last two shifts have been hellish. Busy, busy, busy, punctuated by flail and trauma.
A patient bought beer for the ED staff, however, and I intend to finish my shift drinking one in the Ambulance Bay. Merry Shrooming Christmas.
Tonight, my last for a few days, was eerily quiet. Quite nice, actually; but a quiet department makes me nervous. It's superstition, I know, but I also know it means something shit is waiting.
Tonight was no exception.
Having begun to think that we might make it through, actually having an entire shift that was nice and quiet, the BatPhone trilled into life. While this usually means someone unwell, we do get a variety of stuff phoned through. If you're dying, you'll come through on the phone, but if you come through on the phone, you ain't necessarily dying.
First, a cardiac arrest. I'm embarrassed to say that I can't remember how old he was, even though he slipped away from us less than an hour ago. 70s, I think. The crew that brought him had been going an hour, with no encouraging signs. There's really no comeback once you've been dancing with the Angels that long, but we'll try. The team is ready, and eager; callous though it may sound, it's also a good opportunity for the juniors to try their hands at running an arrest.
Another 30 minutes with us and we were finally ready to accept what we all knew was true. So my SHO got to learn the art of breaking bad news; this time of year it seems especially cruel.
As we were getting our breath back, the unwelcome trilling rang out again. Another gent, 70s again; bellyache, low blood pressure, poorly responsive. Time only to wipe our brows and breath in.
When he arrives, I can see he's in trouble. A raven might as well have been perched on his shoulder. He had apparently gone off as soon as the Ambos arrived, slipping into unconsciousness, and abandoning all attempts at breathing. His pulse, fluttering, weak, thready; barely evidence of a tenuous hold on life.
It didn't last.
Within minutes, he was gone. We were still gathering obs, still trying to make sense of the puzzle before us when he lost his fight. CPR started immediately, and I tubed him; slick as you like - Grade 1 view, some airway soiling, but the semi rigid, impersonal endotracheal tube whipped between his cords as easy as you like. Forcing air into him desperately, I couldn't tear my eyes off his belly, which was blowing up in front of our eyes.
For a few frantic, soul searching moments my 'satisfaction' with the tube turned to self doubt.
'It's in his fucking oesophagus...'
Then the CO2 monitor lit up. CO2 only comes from the lungs, so the tube couldn't be anywhere else. I think that might be called 'cold comfort'.
Another undignified struggle. Nothing made any difference; every intervention a small victory, but in a losing campaign. As is so often the case, all the cajoling, all the pleading in the world, couldn't get his heart started.
My turn to talk to the family. The usual explanations; the apologetic, quietly spoken words. I don't know how they hear them, but they echo dully in my own head.
And finally, they take it in, for now anyway - tomorrow will be different, and the next day, until the realisation finally takes root - and they thank me.
'For all you did for him'
For ruining Christmas
Monday, December 17, 2007
All Wang-Eyed, And Nowhere To Go
Further confirmation, if it were necessary, that i can, on occasion, function on bugger all sleep. But the drive back was... interesting. And although I feel dead on my feet, I'm very fearful that I will elude the arms of Morpheus again tonight. I don't think I can do it again.
And so to work; it's man flu season. Even some of the female nurses were admitting to it. I'm sure that's 'bird-flu', but anyway...
I guess I must have looked more pasty than usual; I sure as hell felt it. It was all I could do to not throw up when I got in. Sure, I can work on no sleep, but it ain't clever. Domperidone sorted that out. Resus was in full swing when I arrived. Baby blue pyjamas knows. He was there. I missed all the action, but did get a chance to relocate a posterior shoulder dislocation, something I haven't tried before. It seemed simple enough, and one of my SHOs and I produced a satisfying clunk. Smug mode all round.
Nope. Apparently, one clunk does not a relocation make. I'm sure it went back, but slipped out again, while we were assessing stability; or when the Radiographers were X-Raying it. Yes, that was definitely it...
So.... the Boss asked me to check out a fella who had had his legs unpleasantly squashed in an RTC. As he put it, when the car in front stopped, he stopped about six inches too late. One bust patella, and a mashed radius. As luck would have it, this was today's lucky combo for an Ortho admit.
Meanwhile... the Boss reattempted the shoulder. I was quite pleased to see he appeared to struggle with it too; until BBP stepped into the breach. Before you could say 'counter-traction' there was a distinctly lesser clunk, but a whole lot more reduced joint. Next time for Shroom, I guess. I just have to remember to take BBP wth me...
I have more wisdom to impart (well, true for a certain value of the word 'wisdom'), but I really am tired... So, until I edit, a reminder to myself - wang-eyed, end of the night shift and nursing scut vs doctor scut.
And so to work; it's man flu season. Even some of the female nurses were admitting to it. I'm sure that's 'bird-flu', but anyway...
I guess I must have looked more pasty than usual; I sure as hell felt it. It was all I could do to not throw up when I got in. Sure, I can work on no sleep, but it ain't clever. Domperidone sorted that out. Resus was in full swing when I arrived. Baby blue pyjamas knows. He was there. I missed all the action, but did get a chance to relocate a posterior shoulder dislocation, something I haven't tried before. It seemed simple enough, and one of my SHOs and I produced a satisfying clunk. Smug mode all round.
Nope. Apparently, one clunk does not a relocation make. I'm sure it went back, but slipped out again, while we were assessing stability; or when the Radiographers were X-Raying it. Yes, that was definitely it...
So.... the Boss asked me to check out a fella who had had his legs unpleasantly squashed in an RTC. As he put it, when the car in front stopped, he stopped about six inches too late. One bust patella, and a mashed radius. As luck would have it, this was today's lucky combo for an Ortho admit.
Meanwhile... the Boss reattempted the shoulder. I was quite pleased to see he appeared to struggle with it too; until BBP stepped into the breach. Before you could say 'counter-traction' there was a distinctly lesser clunk, but a whole lot more reduced joint. Next time for Shroom, I guess. I just have to remember to take BBP wth me...
I have more wisdom to impart (well, true for a certain value of the word 'wisdom'), but I really am tired... So, until I edit, a reminder to myself - wang-eyed, end of the night shift and nursing scut vs doctor scut.
Saturday, December 08, 2007
Car-Nage
Another hot one...
Some of our 4pm til midnight shifts have slipped two hours, to become 6pm til 2 am shifts. Today's was just such a shift. Joyfully, I had booked a patient to come back for review at 4. I duly set off to make the commute; today, of all days, the traffic was shite. This coincided with my reaffirming my theory about drinking plenty of water. 3 litres a day? Balls. I am not convinced this makes me any healthier. It does make me piss like a racehorse. So, en route today, I dutifully drank a litre of God's finest tapwater. My timing is usually such that I arrive just in time to void, copiously.
Not today.
Constant reader, if you are not desirous of learning more than you really need about my bladder, look away now.
I made one pitstop about halfway, to stretch the Shroom's stumpy little legs, and add my contribution to the groundwater. The traffic jam 20 minutes away from work subjected me to the trials of patience peculiar to the bladder. I almost made it; but at the last, had to pull over. On this occasion, I could not find an appropriate bush to water, so was able to recycle my water bottle. And I filled it to the brim. A whole litre! Which went some way to explain why my back teeth had been floating. And yet 10 minutes later, once I got to work, I was able to void further. I didn't have a urometer to hand on this occasion, but reckon I passed another 500. So, one litre in, probably 2 out. I am the king of diuresis.
'Rehydration' my stretchy bladder.
Uriniferous miasma passed.
The department was once again heaving. My favourite boss asked me to weigh in early. I have so little life. I gladly accepted. Another shift in resus. Maybe I can get a little cot in the corner, and move in. It'll sure as hell cut down on my commute costs.
So - COPD decompensating in Bay one; serious trauma in 2 (donorcycle versus car); haemoptysis in 3. He ended up there because of a history of gastric carcinoma and abdominal aneurysm. He was pretty well, all things considered, which gave me time to goggle at the fact that bay 2 guy had done almost the same thin a year ago. He is surely getting the most out of his NHS tax dollar, but using up his nine lives, eh? I didn't quite keep up with what his injuries were this time, but our resus was for a time home to all the intensivists our little hospital has to offer.
The stability of haemoptysis man was further useful as it enabled a quick switch for status epilepticus girl. This wee lassie's story is confused by her non-diagnosis. We are all agreed that she has fits, but no-one knows why. The Neuro guys are pretty sure it ain't epilepsy; the Head shrinkers are pretty sure it ain't psychological; and the cardiac guys are wondering what it has to do with them. So far as I can tell, all tests are normal... which more or less adds up to 'psychological' seizures. Or pseudo-fits. The problem with this diagnosis is the stigma attached. It tends to be equated with 'faking it'. This patient certainly felt she wasn't being taken seriously by medical personnel, once they found out her non-epileptic diagnosis. And as far as I can tell, her fits were not epileptic, although I can see how they would appear to be to a lay person.
Does that change how I treat her? No, except possibly in that I'm less likely to give her benzos, or other anti-convulsants. Fits are fits; they still fuck up your day. Personally, I think they are psychological, but what do I know. I suspect this diagnosis will not ever be accepted by the family, or the patient. And as such, I'm not sure if she'll get better. Speaking to the family, it seemed to me that they considered the very idea offensive. I'm not sure this is fair. Like I say, fitting is fitting. Why should there be less stigma to a fit that has an 'organic' cause, as opposed to one that is 'psychological'? I guess this small question holds the nub of the stigma associated with all mental health issues.
Fuck it, what do I know?
A few more fits later, and a brief argument with the Magicians, and our lassie won a bed for the night. I hope her test results eventually tell her what she wants, and some treatment can be started.
She made way for a fracture dislocation of an ankle. Normally my bread and butter, I just could not relocate this one. I sheepishly had to turf to ortho. Macho Shroom? Not this day...
And with her passage out of the House of Fun, my nightly MI arrived. The MI that never was, fortunately. Brief panic, then transfer to CCU. Joy, and medicine of the highest quality. A few Paeds cases brought on the double bunking that seems de rigeur these days; in fact I even had the pleasure of treating a few in the corridor. To their eternal credit, the parents were understanding, and probably just glad to see a doctor. First world care, you see...
My shift ended with a smattering of trauma. Another donorcyclist, this one who worked in a brewery, and smelled like it, but seemed to have got away with facial injuries. The usual survey was complicated by the patients spectacularly awful dentition. He barely had a single tooth in his mouth, and could not tell me if this was how God intended him to be, or if the offending ivories might be nestling in his pulmonary nooks and crannies. At the same time, there was a great stacking of motor vehicles somewhere far to the north, disgorging copious numbers of inebriated youths, in various stages of injury. A major incident beckoned, but we were fortunate enough to be able to share the wealth with several sister hospitals. But this still left my colleague snowed under as the witching hour drew nigh.
A man of no doubt the highest moral fibre completed my night by overdosing on cocaine and heroin; an interesting combo, and another repeat offender, I noted with, sadly, little surprise.
My journey home was illuminated by the particularly piercing incandescent blues unique to ambulances. Erie when they aren't blaring the two tones... Over for the night?
Not even started, my friends
Some of our 4pm til midnight shifts have slipped two hours, to become 6pm til 2 am shifts. Today's was just such a shift. Joyfully, I had booked a patient to come back for review at 4. I duly set off to make the commute; today, of all days, the traffic was shite. This coincided with my reaffirming my theory about drinking plenty of water. 3 litres a day? Balls. I am not convinced this makes me any healthier. It does make me piss like a racehorse. So, en route today, I dutifully drank a litre of God's finest tapwater. My timing is usually such that I arrive just in time to void, copiously.
Not today.
Constant reader, if you are not desirous of learning more than you really need about my bladder, look away now.
I made one pitstop about halfway, to stretch the Shroom's stumpy little legs, and add my contribution to the groundwater. The traffic jam 20 minutes away from work subjected me to the trials of patience peculiar to the bladder. I almost made it; but at the last, had to pull over. On this occasion, I could not find an appropriate bush to water, so was able to recycle my water bottle. And I filled it to the brim. A whole litre! Which went some way to explain why my back teeth had been floating. And yet 10 minutes later, once I got to work, I was able to void further. I didn't have a urometer to hand on this occasion, but reckon I passed another 500. So, one litre in, probably 2 out. I am the king of diuresis.
'Rehydration' my stretchy bladder.
Uriniferous miasma passed.
The department was once again heaving. My favourite boss asked me to weigh in early. I have so little life. I gladly accepted. Another shift in resus. Maybe I can get a little cot in the corner, and move in. It'll sure as hell cut down on my commute costs.
So - COPD decompensating in Bay one; serious trauma in 2 (donorcycle versus car); haemoptysis in 3. He ended up there because of a history of gastric carcinoma and abdominal aneurysm. He was pretty well, all things considered, which gave me time to goggle at the fact that bay 2 guy had done almost the same thin a year ago. He is surely getting the most out of his NHS tax dollar, but using up his nine lives, eh? I didn't quite keep up with what his injuries were this time, but our resus was for a time home to all the intensivists our little hospital has to offer.
The stability of haemoptysis man was further useful as it enabled a quick switch for status epilepticus girl. This wee lassie's story is confused by her non-diagnosis. We are all agreed that she has fits, but no-one knows why. The Neuro guys are pretty sure it ain't epilepsy; the Head shrinkers are pretty sure it ain't psychological; and the cardiac guys are wondering what it has to do with them. So far as I can tell, all tests are normal... which more or less adds up to 'psychological' seizures. Or pseudo-fits. The problem with this diagnosis is the stigma attached. It tends to be equated with 'faking it'. This patient certainly felt she wasn't being taken seriously by medical personnel, once they found out her non-epileptic diagnosis. And as far as I can tell, her fits were not epileptic, although I can see how they would appear to be to a lay person.
Does that change how I treat her? No, except possibly in that I'm less likely to give her benzos, or other anti-convulsants. Fits are fits; they still fuck up your day. Personally, I think they are psychological, but what do I know. I suspect this diagnosis will not ever be accepted by the family, or the patient. And as such, I'm not sure if she'll get better. Speaking to the family, it seemed to me that they considered the very idea offensive. I'm not sure this is fair. Like I say, fitting is fitting. Why should there be less stigma to a fit that has an 'organic' cause, as opposed to one that is 'psychological'? I guess this small question holds the nub of the stigma associated with all mental health issues.
Fuck it, what do I know?
A few more fits later, and a brief argument with the Magicians, and our lassie won a bed for the night. I hope her test results eventually tell her what she wants, and some treatment can be started.
She made way for a fracture dislocation of an ankle. Normally my bread and butter, I just could not relocate this one. I sheepishly had to turf to ortho. Macho Shroom? Not this day...
And with her passage out of the House of Fun, my nightly MI arrived. The MI that never was, fortunately. Brief panic, then transfer to CCU. Joy, and medicine of the highest quality. A few Paeds cases brought on the double bunking that seems de rigeur these days; in fact I even had the pleasure of treating a few in the corridor. To their eternal credit, the parents were understanding, and probably just glad to see a doctor. First world care, you see...
My shift ended with a smattering of trauma. Another donorcyclist, this one who worked in a brewery, and smelled like it, but seemed to have got away with facial injuries. The usual survey was complicated by the patients spectacularly awful dentition. He barely had a single tooth in his mouth, and could not tell me if this was how God intended him to be, or if the offending ivories might be nestling in his pulmonary nooks and crannies. At the same time, there was a great stacking of motor vehicles somewhere far to the north, disgorging copious numbers of inebriated youths, in various stages of injury. A major incident beckoned, but we were fortunate enough to be able to share the wealth with several sister hospitals. But this still left my colleague snowed under as the witching hour drew nigh.
A man of no doubt the highest moral fibre completed my night by overdosing on cocaine and heroin; an interesting combo, and another repeat offender, I noted with, sadly, little surprise.
My journey home was illuminated by the particularly piercing incandescent blues unique to ambulances. Erie when they aren't blaring the two tones... Over for the night?
Not even started, my friends
Tuesday, November 27, 2007
A Night of Two Halves
Busy Busy Busy.
Interesting. The department was, once again, heaving when I came on last night. Patients queuing to get off ambulances, and mustachioed doctors groaning under the workload. A full hospital. I note that when this happened to the Norfolk and Norwich, they declared a 'code black' and made the news...
Two incidents stand out for me. Firstly, there was the delightful lady who seemed to think that because she had taken an overdose, she could behave as she wished. She took the opportunity to subject everyone within reach to a torrent of the foulest, most bilious abuse imaginable. She topped off her performance with a fine array of spitting. A command performance.
Having determined that her overdose required little in the way of acute management, we disabused her of her ideas about entitlement by having her arrested.
Next I once again had the pleasure of double bunking in resus. In a sort of homage to Steve Martin in the 'Man with Two Brains' I simultaneously treated 3 teens from an RTC. Single vehicle vs tree; they were all in reasonable shape, which was more than could be said for the car.
After this, the night fairly flew by. By six, all was quiet... for about 3 seconds. It was then that the patient handed over to me, with the fateful words "He'll be fine, you won't need to do anything", started fitting.
The fit subsided fairly promptly, but the spreading petechial rash, and frank blood in his catheter bag did not ease our minds. To compound matters, just as the possibility of meningococcaemia was rearing its ugly head, a young woman 2 weeks post chemo was wheeled in.
Now, for those of you unsure, chemotherapy, for all its many benefits, rogers your immune system good and proper. So, once that's happened, one becomes subject to all sorts of previously harmless infections. The hospital often beckons. But next to a patient teaming with meningococcus is low on the list of places you wanna be.
A bit of juggling later, we had achieved isolation. Of sorts. But the department had backed up sufficiently to give the morning crew the impression that we'd done buggerall over night.
Ah well.
On a lighter note, I was able to review some CT scans. These were of the cervical spine of an elderly patient. It was this patient whose condition I was afraid I had misdiagnosed. Had missed.
The CT supported my original diagnosis.
This is good for a number of reasons.
1) The patient does not have a broken neck
2)The patient does not have a spinal injury
3)I didn't miss a spinal fracture.
The altruistic Shroom is clearly glad that this means the patient is well.
(But it's quite nice to know I didn't make a mistake, for the sake of not having made a mistake...)
Interesting. The department was, once again, heaving when I came on last night. Patients queuing to get off ambulances, and mustachioed doctors groaning under the workload. A full hospital. I note that when this happened to the Norfolk and Norwich, they declared a 'code black' and made the news...
Two incidents stand out for me. Firstly, there was the delightful lady who seemed to think that because she had taken an overdose, she could behave as she wished. She took the opportunity to subject everyone within reach to a torrent of the foulest, most bilious abuse imaginable. She topped off her performance with a fine array of spitting. A command performance.
Having determined that her overdose required little in the way of acute management, we disabused her of her ideas about entitlement by having her arrested.
Next I once again had the pleasure of double bunking in resus. In a sort of homage to Steve Martin in the 'Man with Two Brains' I simultaneously treated 3 teens from an RTC. Single vehicle vs tree; they were all in reasonable shape, which was more than could be said for the car.
After this, the night fairly flew by. By six, all was quiet... for about 3 seconds. It was then that the patient handed over to me, with the fateful words "He'll be fine, you won't need to do anything", started fitting.
The fit subsided fairly promptly, but the spreading petechial rash, and frank blood in his catheter bag did not ease our minds. To compound matters, just as the possibility of meningococcaemia was rearing its ugly head, a young woman 2 weeks post chemo was wheeled in.
Now, for those of you unsure, chemotherapy, for all its many benefits, rogers your immune system good and proper. So, once that's happened, one becomes subject to all sorts of previously harmless infections. The hospital often beckons. But next to a patient teaming with meningococcus is low on the list of places you wanna be.
A bit of juggling later, we had achieved isolation. Of sorts. But the department had backed up sufficiently to give the morning crew the impression that we'd done buggerall over night.
Ah well.
On a lighter note, I was able to review some CT scans. These were of the cervical spine of an elderly patient. It was this patient whose condition I was afraid I had misdiagnosed. Had missed.
The CT supported my original diagnosis.
This is good for a number of reasons.
1) The patient does not have a broken neck
2)The patient does not have a spinal injury
3)I didn't miss a spinal fracture.
The altruistic Shroom is clearly glad that this means the patient is well.
(But it's quite nice to know I didn't make a mistake, for the sake of not having made a mistake...)
Tuesday, November 13, 2007
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.
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.
Sunday, November 11, 2007
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.
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.
Thursday, November 08, 2007
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...
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.
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.
Wednesday, November 07, 2007
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.
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.
Wednesday, June 06, 2007
Thomas Muir of Huntershill
Google it.
Maudlin again. Too many late nights and whiskey, I guess.
A couple of the blogs I like to read have gone invite only. I'm sorry if my side bar links lead you to a dead end. I'm slightly disappointed. I liked reading them - but folks have to do what they have to do, I guess.
I'm increasingly anxious about blogging my day to day work life here. Mostly because I'm less and less anonymous, and confidentiality is a huge part of what we do. Still, I'll try, for what it's worth.
Recently I've struggled with patients who have different ideas about what their best interests are than I do. Here's an example:
Let's suppose you elect to spend the afternoon drinking heavily. A few litres of your chosen spirit should do it, but feel free to wash it down with some beer chasers. I'm ok with that.
Next injure yourself; ideally, you should make the mechanism, the way in which you hurt yourself high risk - crash your car, fall off a bridge, you get the idea. BUT, and this is crucial, have little objective evidence of injury. A few grazes, here and there. Nothing spectacular, like being in more pieces than the good Lord intended.
On arrival at hospital, you should then slur your words, most of which should be Anglo-Saxon epithets anyway, and try to attack all hospital staff. This will involve removal of all the carefully applied devices protecting your cervical spine.
I am now left with the choice of allowing you to leave my department, with the knowledge that you might have significant occult injury, or restraining you, possibly at risk to my own health. I can guess that the way you are behaving is most likely an amplification of your own personality by your booze of choice... but it might just as well be your nascent extra-dural haematoma.
If the former, you'll wake up with a hangover, assuming you don't walk into traffic; if the latter, you won't wake up at all.
But, if I hold you down, and inject magic drugs into you, I have to be certain you don't have capacity, or I'm assaulting you.
I once treated a patient who was threatening to kill me; he has been my only stalker to date. I don't think I've blogged this before; I'll check - it might make good press. Anyway, I was reluctant to deal with a fella who was actively trying to stab me. My defence organisation informed me I had a duty of care unto him, right up until he actually did stab me.
I have to confess, I took my career into my own hands, and went against their advice, refusing to treat him. (It was neither a life, or limb threatening injury, for the record)
This country does not seem to have grasped the nettle of treating the (potentially) deranged, violent patient, who may simply be an arse, or may be acting like an arse because of their injury...
As for the example above... it might end like this:
You escape serious head injury, but turn out to have a broken neck. Despite assaulting every member of staff who comes near you, you avoid permanent paralysis. You wake up the next day with a hangover, and immediately discharge yourself from hospital, presumably reasoning that if the neck didn't give out during the fighting, it's good to go.
Sometimes, I wonder where my spirit went.
Maudlin again. Too many late nights and whiskey, I guess.
A couple of the blogs I like to read have gone invite only. I'm sorry if my side bar links lead you to a dead end. I'm slightly disappointed. I liked reading them - but folks have to do what they have to do, I guess.
I'm increasingly anxious about blogging my day to day work life here. Mostly because I'm less and less anonymous, and confidentiality is a huge part of what we do. Still, I'll try, for what it's worth.
Recently I've struggled with patients who have different ideas about what their best interests are than I do. Here's an example:
Let's suppose you elect to spend the afternoon drinking heavily. A few litres of your chosen spirit should do it, but feel free to wash it down with some beer chasers. I'm ok with that.
Next injure yourself; ideally, you should make the mechanism, the way in which you hurt yourself high risk - crash your car, fall off a bridge, you get the idea. BUT, and this is crucial, have little objective evidence of injury. A few grazes, here and there. Nothing spectacular, like being in more pieces than the good Lord intended.
On arrival at hospital, you should then slur your words, most of which should be Anglo-Saxon epithets anyway, and try to attack all hospital staff. This will involve removal of all the carefully applied devices protecting your cervical spine.
I am now left with the choice of allowing you to leave my department, with the knowledge that you might have significant occult injury, or restraining you, possibly at risk to my own health. I can guess that the way you are behaving is most likely an amplification of your own personality by your booze of choice... but it might just as well be your nascent extra-dural haematoma.
If the former, you'll wake up with a hangover, assuming you don't walk into traffic; if the latter, you won't wake up at all.
But, if I hold you down, and inject magic drugs into you, I have to be certain you don't have capacity, or I'm assaulting you.
I once treated a patient who was threatening to kill me; he has been my only stalker to date. I don't think I've blogged this before; I'll check - it might make good press. Anyway, I was reluctant to deal with a fella who was actively trying to stab me. My defence organisation informed me I had a duty of care unto him, right up until he actually did stab me.
I have to confess, I took my career into my own hands, and went against their advice, refusing to treat him. (It was neither a life, or limb threatening injury, for the record)
This country does not seem to have grasped the nettle of treating the (potentially) deranged, violent patient, who may simply be an arse, or may be acting like an arse because of their injury...
As for the example above... it might end like this:
You escape serious head injury, but turn out to have a broken neck. Despite assaulting every member of staff who comes near you, you avoid permanent paralysis. You wake up the next day with a hangover, and immediately discharge yourself from hospital, presumably reasoning that if the neck didn't give out during the fighting, it's good to go.
Sometimes, I wonder where my spirit went.
Thursday, January 18, 2007
The Summer Had Inhaled, And Held It's Breath Too Long
There was supposed to be a part the second, and indeed a part the third yesterday, but technical difficulties intervened.
---Anyway; what had been on my mind was continuity of care. This has had the habit of picking up controversy from time to time. Like fluff on your favourite shirt, if you will. Mostly because some people think patients used to get it, and that they don't anymore. Either way, Emergency Medicine has never been about long term continuity of care; and this fact holds much of its appeal to some people. Such as your resident fungus. So it is in that context that I say I don't much care for it. I enjoy avoiding ward rounds and clinics as much as possible.
---However, it is occasionally nice to see what has happened to memorable patients that pass through the Department. Now, obviously, I care deeply about the fate of every living thing I encounter, but some I am happy to trust to my erudite colleagues in the rest of the hospital, and others I try to follow up myself. Either to see them and wish them well, or to see what the blue blazes was actually wrong with them (which can, of course, allow the occasional smug(implied) 'I told you so' to be floated)... as in:
---Anyway; what had been on my mind was continuity of care. This has had the habit of picking up controversy from time to time. Like fluff on your favourite shirt, if you will. Mostly because some people think patients used to get it, and that they don't anymore. Either way, Emergency Medicine has never been about long term continuity of care; and this fact holds much of its appeal to some people. Such as your resident fungus. So it is in that context that I say I don't much care for it. I enjoy avoiding ward rounds and clinics as much as possible.
---However, it is occasionally nice to see what has happened to memorable patients that pass through the Department. Now, obviously, I care deeply about the fate of every living thing I encounter, but some I am happy to trust to my erudite colleagues in the rest of the hospital, and others I try to follow up myself. Either to see them and wish them well, or to see what the blue blazes was actually wrong with them (which can, of course, allow the occasional smug(implied) 'I told you so' to be floated)... as in:
Shroom: Ah, hello Mr Surgical Reg
Reg: Shroom; aren't you an A&E weasel? Why have you darkened the doors of my surgical shrine? I mean, ward?
Shroom: Just checking on Mrs Abdo Pain from yesterday. You know, the one you said had a UTI (urinary tract infection)
Reg: Turned out she had an aneurysm. We opened her last night.
Shroom: Aneurysm. My goodness. Gosh. Didn't someone suggest that yesterday... I could have sworn they did...
Reg: **grunt**
Shroom: No. That's right. It was ME! I said 'I think it's an aneurysm' and you said 'Fuck off, is it'; or something... well, fancy that. Funny how things go, eh?
I am perhaps a little less direct, but, I suspect, often just as annoying.
Sometimes, I think it's better not to know. The fella I saw last week who'd come off his bike, with two smashed knees has been waiting days for transfer. At the time his partner asked if he might lose a leg. Having seen injuries like these before I had to admit it was possible, but, rather foolishly tried to downplay the idea. Privately, I felt sure he had a high chance of ending up with at least one amputation at some point, and the longer he waits for definitive surgery, the more debridement that goes on, the more likely this seems.
After what seems like months of driving rain, and flooding throughout the country, I was delighted to hear today that my local water company up London has finally lifted the hosepipe ban. The irony is almost killing me.
---A couple of funny old cases today. The weather was again dominated by gales and driving winds - gusting around the 90 -100 mph mark they tell me. This is more than enough to knock over pensioners on giro day. However our first was a fella who fell off a roof, trying to rescue a cat. Despite looking as if he had sustained multiple injuries, I couldn't find a damn thing wrong with him. We admitted him anyway, in case there was something lurking (I particularly distrust the retroperitoneum. I would advise you all, especially those in the legal profession, to make this top of your list of Body Cavities You Don't Trust. It surely tops mine.)
The second was an older lady, who despite looking well enough from end of bed, I couldn't find a damn thing right with her. She is one I'll follow up on...
Wednesday, January 03, 2007
Wednesday, December 20, 2006
One more friend, blown off the mountain with the wind
I'm beginning to think I write an awful lot of crap. But a few of you seem to come by daily, so I'm guessing not everybody minds.
I'm still feeling shit because:
1) I'm still hacked off about my aneurysm patient.
2) I've still got manflu
3) So has every other bastard in the hospital, and so now I'm covering a night shift, which will delay my holiday break for 12 hours. Bah.
I'm on an education day today, which all too often translates into time sat in font of a monitor not achieving much. This should not surprise many of you reading this... At least I'm resisting the temptation to continue on my quest to re-watch every episode of ER (Series 4, since you were wondering)
To complete the tale of how much Monday sucked balls:
after the trauma that was our unsuccessful resuscitation of the man with the leaking aneurysm, I was all set to resuscitate myself with a cup of tea. (Do any other nationals place so much import in a simple drink? I'm not sure, but, at least in patients over about 50, a cup of tea acts as a mighty panacea...)
That plan went out of the window when, within a very short space of time we received a young epileptic with a worryingly depressed GCS; an unusually heavy man in anaphylactic shock; and a young woman with a severe head injury.
My boss took care of the kiddie (he's fine), my good friend took the anaphylactic (he was actually septic; I haven't had a chance to check up on him), leaving me with the head injury.
Young women with head injuries fill me a little with dread. When I was just a young Turk in the Emergency Department (A&E as was), I treated a young girl with really severe head injuries. It all seemed so senseless then, and this was no different.
Here was this girl, unknown to me, found by her mother and brother, unconscious in her own flat, her face a mis-shapen lumpen mass of bruises. Breathing shallowly and noisily, she lay on our trolley, unprotesting at the cruel invasions of modern medicine - a drip here, a blood sample there, the C-collar, a urinary catheter. I can't even imagine what it must be like to find someone you know in that kind of state. To me, it takes on a degree of unreality. I can only empathise so far, otherwise I'd spend more time weeping than I do already. And that would really put a crimp on my tough-guy image.
Anyway, we got her tubed and ventilated and whipped her down to the CT scanner. A healthy does of ionising radiation failed to show any significant intra-cranial injury, and the ITU beckoned. It's hard to deal with relatives in this sort of situation - when all they want to know is 'what happened?', and 'will she be all right?' and all you can offer is: "We'll have to wait and see".
I don't possess the qualifications to take this opinion into a court of Law, but someone beat the shit out of her.
All so needless.
She went home today.
I'm still feeling shit because:
1) I'm still hacked off about my aneurysm patient.
2) I've still got manflu
3) So has every other bastard in the hospital, and so now I'm covering a night shift, which will delay my holiday break for 12 hours. Bah.
I'm on an education day today, which all too often translates into time sat in font of a monitor not achieving much. This should not surprise many of you reading this... At least I'm resisting the temptation to continue on my quest to re-watch every episode of ER (Series 4, since you were wondering)
To complete the tale of how much Monday sucked balls:
after the trauma that was our unsuccessful resuscitation of the man with the leaking aneurysm, I was all set to resuscitate myself with a cup of tea. (Do any other nationals place so much import in a simple drink? I'm not sure, but, at least in patients over about 50, a cup of tea acts as a mighty panacea...)
That plan went out of the window when, within a very short space of time we received a young epileptic with a worryingly depressed GCS; an unusually heavy man in anaphylactic shock; and a young woman with a severe head injury.
My boss took care of the kiddie (he's fine), my good friend took the anaphylactic (he was actually septic; I haven't had a chance to check up on him), leaving me with the head injury.
Young women with head injuries fill me a little with dread. When I was just a young Turk in the Emergency Department (A&E as was), I treated a young girl with really severe head injuries. It all seemed so senseless then, and this was no different.
Here was this girl, unknown to me, found by her mother and brother, unconscious in her own flat, her face a mis-shapen lumpen mass of bruises. Breathing shallowly and noisily, she lay on our trolley, unprotesting at the cruel invasions of modern medicine - a drip here, a blood sample there, the C-collar, a urinary catheter. I can't even imagine what it must be like to find someone you know in that kind of state. To me, it takes on a degree of unreality. I can only empathise so far, otherwise I'd spend more time weeping than I do already. And that would really put a crimp on my tough-guy image.
Anyway, we got her tubed and ventilated and whipped her down to the CT scanner. A healthy does of ionising radiation failed to show any significant intra-cranial injury, and the ITU beckoned. It's hard to deal with relatives in this sort of situation - when all they want to know is 'what happened?', and 'will she be all right?' and all you can offer is: "We'll have to wait and see".
I don't possess the qualifications to take this opinion into a court of Law, but someone beat the shit out of her.
All so needless.
She went home today.
Saturday, December 09, 2006
Going Nursical
Brilliant. The title bears no real relation to the post, but a fellow Blogonaut - the Bohemian Road Nurse - left it, and I thought it too good a phrase to lie hidden. I hope she won't mind.
So, I have returned. I've spent the last few days on a fairly intensive ATLS course. This is the Advanced Trauma Life Support course, care of the American College of Surgeons. It teaches one safe way of caring for the trauma victim. The courses are pretty good fun, but fairly hard work. Since part of my job involves looking after trauma victims (or at least the British definition - we don't have much "proper" trauma per se) I expected, and was expected to do well. Which generally increases the potential to fuck up. In front of the boss.
Well, you'll all be pleased to hear I managed to avoid all / most banana skins. I am now all shiny in the ATLS fashion. It is interesting to see that not much has changed since I first did the course six years ago. I tend to find these courses are arbitrary, as they are trying to teach a UNIVERSAL method, which is 'proven' to be safe. Trauma care is especially difficult to get evidence for - it's very hard to ethically justify depriving multiply injured patients of care to see how it affects outcome. Getting consent can be a real bitch, too! A good case in point is the use of steroids in head injuries. This was considered a gospel treatment, in the UK at least, for years. Only relatively recently has it become apparent that not only did this not improve outcome, it actually does harm. Primum non nocere? Ooops.
Consequently, as far as I can see, most of the developments in trauma care originate with the military - WWI, WWII, Vietnam, Falklands, Afghanistan and now Iraq. Wherever there's a war, there are large numbers of traumatised patients... of course, they're mostly young, fit men and women. Or pigs. It always seems to be pigs that the military surgeons practice on...
So extrapolating data to the real world, which is slowly filling with fat, older people, may not work. Even so, I was disappointed not to see any comment on issues such as permissive hypotension / hypothermia. I seem to remember these being contentious issues six years ago, and I guess the picture's no clearer.
Thanks again B.R.N
So, I have returned. I've spent the last few days on a fairly intensive ATLS course. This is the Advanced Trauma Life Support course, care of the American College of Surgeons. It teaches one safe way of caring for the trauma victim. The courses are pretty good fun, but fairly hard work. Since part of my job involves looking after trauma victims (or at least the British definition - we don't have much "proper" trauma per se) I expected, and was expected to do well. Which generally increases the potential to fuck up. In front of the boss.
Well, you'll all be pleased to hear I managed to avoid all / most banana skins. I am now all shiny in the ATLS fashion. It is interesting to see that not much has changed since I first did the course six years ago. I tend to find these courses are arbitrary, as they are trying to teach a UNIVERSAL method, which is 'proven' to be safe. Trauma care is especially difficult to get evidence for - it's very hard to ethically justify depriving multiply injured patients of care to see how it affects outcome. Getting consent can be a real bitch, too! A good case in point is the use of steroids in head injuries. This was considered a gospel treatment, in the UK at least, for years. Only relatively recently has it become apparent that not only did this not improve outcome, it actually does harm. Primum non nocere? Ooops.
Consequently, as far as I can see, most of the developments in trauma care originate with the military - WWI, WWII, Vietnam, Falklands, Afghanistan and now Iraq. Wherever there's a war, there are large numbers of traumatised patients... of course, they're mostly young, fit men and women. Or pigs. It always seems to be pigs that the military surgeons practice on...
So extrapolating data to the real world, which is slowly filling with fat, older people, may not work. Even so, I was disappointed not to see any comment on issues such as permissive hypotension / hypothermia. I seem to remember these being contentious issues six years ago, and I guess the picture's no clearer.
Thanks again B.R.N
Sunday, October 29, 2006
Things that made me smile
No. 1 in an occasional series
--- Many years ago, when Shroom was just a little fungus, he was asked to come review a patient. He had learned that when some nurses asked you to come, you came a'running; so he came apace. "I'm worried about this guy. He's blue"
Blue should also be on the list of colours you're not.
--- Many years ago, when Shroom was just a little fungus, he was asked to come review a patient. He had learned that when some nurses asked you to come, you came a'running; so he came apace. "I'm worried about this guy. He's blue"
Blue should also be on the list of colours you're not.
Rounding the corner I was confronted with the patient. Sure enough, he was blue. But he looked well with it. He was not 'so cold I'm blue' blue, or 'so breathless I'm blue' blue. Just blue.
This puzzled me. It was a dreadful night, and the guy was sleeping rough, but he looked so well. To hide my confusion, my eyes scanned the cubicle, finally lighting upon the sad bundle of stuff the patient had abandoned on the floor. It was sopping wet, sitting in a little puddle. A little blue puddle. Picking it up revealed it to be a thick, wet, blue blanket.
"Are you sleeping under this?" Nod, shiver...
Gently, I rubbed his skin; the towel came away blue, the skin beneath gloriously pink. 'Cured, Sister' winks the Shroom; 'needs a new blanket...'
Guilty Pleasures, no. 1
--- I'm secretly delighted every time a Paramedic or Policeman calls me "Doc"
I seem to have a little hope in my heart this morning; I hope this doesn't signal the onset of mania
"Are you sleeping under this?" Nod, shiver...
Gently, I rubbed his skin; the towel came away blue, the skin beneath gloriously pink. 'Cured, Sister' winks the Shroom; 'needs a new blanket...'
Guilty Pleasures, no. 1
--- I'm secretly delighted every time a Paramedic or Policeman calls me "Doc"
I seem to have a little hope in my heart this morning; I hope this doesn't signal the onset of mania
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