Suequelae

Right. First off, I started to allow comments and I've been spammed. I didn't know there were blog spammers. There's this book on parasitism by Mark Ridley where he reckons parasites are basially the reason for the otherwise costly, dangerous and inconvenient practice of sex. We all have sex so our children don't have the same parasites as we do. And it's almost a rule of nature that they will appear in any sufficiently complex system: parasites are a sign of life.

So there really is a blogosphere.

Anyway, one of the nights I'm so glad I'm writing this anonymously.

Last night I was on night shift at Florey. Before I go on I should point out that Florey is one of, if not the, best Emergency Departments in the city. But it's a small city, and we have the same problems as every other emergency department. Numbers of patients on the rise - projected by some to triple in the next twenty years. Number of GPs willing to service them free dropping like a rock. Number of emergency trainees not rising fast enough, if at all.

And so last night at Florey we had Iskandar Hassan (a few years ahead of me and with anaesthetics experience but someone who has yet to pass the primary) and me in charge, along with two diligent and intelligent interns who are only a few months out of graduation, and it all went fine until five o'clock in the morning. By fine I mean the usual heart attacks and croupy babies and some girl with panic attacks and so forth.

And at about five there's a priority two (meaning guidelines say see this patient within ten minutes) and they wheel in this twenty eight year old woman the colour of Dover chalk.

I have never seen anyone that white. The same colour as the bedsheets. Linen skin.

Anyway, she'd walked into the ED and the triage nurse had seen that she was translucent and had a respiratory rate of thirty (that's thirty breaths a minute, if you try this at home you will collapse), and an unrecordable blood pressure and had given her practically the highest priority that can be given to a living creature and got her around to see us.

I saw her and called Iskandar. She said she had pain in her belly and when I felt it it was like a rock, tighter than any muscle can make it, blown up from the inside like a drum. I got a big line in (thank Christ I went for a white, not a pink) both elbows and we started pouring in fluids. I got some blood and we ran it and her haemoblobin was 102, which is not that bad on the face of it but we knew it was because of haemoconcentration - hardly any haemoblobin in hardly any circulating blood volume, fake good news. All her blood was inside her sail-taut belly.

She said her only medical history was endometriosis and Iskandar was on the phone calling gynae reg while we poured the fluid in and did the ECG and drew the bloods and some nurse got blankets and we tried to find out more. And we got gynae and surgery registrars down (registrar means a member of a training programme - gynae [tall, Singaporean, bearded, reassuring], is training to be a gynaecologist, and surg [dark, English, quick-witted, ironic, calming] is training to be a surgeon, and then we got anaesthetics down for good luck and if I could have called a specialist in psychoneuroendocrine dermatology of the left nostril I would have.

Anyway. Every man and his dog is in the cubicle and I decided not to take her to resus. Resus is really no better than one of the high intensity cubicles, everything we have in a high intensity cubcile we have in resus and vice versa, but maybe I'd change that if I ran the tape again. Probably not.

Then there was all this fucking about. Gynae wanted an ultrasound. This woman had had forty milligrams of morphine with no discernable result. Her fiance is weeping in the corridor and I keep trying to get a better picture, because by now not enough blood is getting to this woman's brain to keep her thinking straight. And what blood there is is acid. We pumped her full of O negative.

At this stage our differential diagnoses are:

some bleeding thing to do with her endometriosis
some bleeding gynae thing, either an ectopic pregnancy or some monster cyst
some big gastro-intestinal bleed, probably a perforated ulcer
with the latter moving rapidly up the charts.

Anyhow, this is where I went wrong. Gynae orders the ultrasound. It takes valuable tens of minutes to obtain and perform. It does not give us a definitive diagnosis. Gynae gets on the phone to his boss, who clears the woman for surgery. They decide to wheel her up for surgery, via Xray. She is sent to xray as far as I can tell, attended only by two nurses. She is very unwell. on the xray table she starts having seizures. A code blue is called. We drag her across onto the barouche, no pulse, dubious heartbeart, not breathing. We are compressing her chest as we wheel her into the closest room: resuscitation.

And it all went to shit from there. I took turns doing cardiac compressions, I suspect we broke her ribs. We slid the greased tube down into her bronchus to breathe for her, and pumped her full of blood. Anyhow, we finally got a heartbeat after close on half an hour and they took her up to surgery (there they detected and repaired the bleeding ulcer she had) and thence to intensive care.

And the reason she got an ulcer at twenty eight was because she had had a lot of pain from her endometriosis and had been surviving on anti-inflammatories like ibuprofen for months while not eating. Don't eat anti-inflammatories on an empty stomach. They will kill you.

What have we learnt today, boys and girls?

Here is the gist, finally. I have learnt some good things. I have learnt that I can recognise danger, that I get help when I am out of my depth, that I can perform basic resuscitative measures.
But I have also learnt something unpleasant about myself.

I am not by nature a leader. I don't know if I am by nature the kind of person who is an emergency doctor. I still see other registrars as senior, as infallible, as people who are in control and who understand. The hard fact is emergency trainees at a certain level are better at managing acute surgical or gynaecological emergencies than are surgical or gynaecological trainees at a certain level. I didn't even think to step in, to say "this woman is unstable, to hell with the ultrasound, take her to theatre." That's what I thought, but I didn't even articulate it, because I had called for expert help when I felt out of my depth and that's all anyone can do, isn't it?

No it's not. If we all did that this woman would have died there in the high intensity cubicle while we all fluttered and twittered and sqeaked like Homer's ghosts.

If I had said that she'd still be here. If I had trusted my knowledge, if I had used my training, if I had been capable of seeing myself as actually competent, this would not have happened.

They say the dangerous doctors aren't the ones who don't know stuff. The dangerous ones are the ones who don't know that they don't know stuff. That's true.

But you're also dangerous if you don't know that you DO know. Because knowledge and expertise is inaccessible if you deny it exists. Caution and not taking risks is one thing, but when it becomes paralysis and not taking action, it's culpable.

I have fifty minutes to the start of the next shift. I'm going scrub myself down, get into my fighting clothes and go out into the world. No-one will die on this shift tonight.

John.

There is lots more I could say about this. What her relatives said, what kind of accent she had, what kind of things made her smile even in unimaginable amounts of pain. But I have to go.

If anyone who knew her (and I've anonymised her pretty well) ever reads this, I am deeply sorry for what happened to you.

John