Friday, May 13, 2005


A very brief post today.

Just finished a run of early morning shifts (start at seven, finish mid afternoon) and I've got that post-clinical fuzz. All wired up and nothing to write about.

Well, there was today's shift.

The morning shift seems like not such a bad shift, but in some weird way it is the most feared.
It is the most feared because of the beast known as the handover.

What happens in emergency (and all other hospital wards) is doctor X is manages a patient for a shift and then s/he hands over the care of the patient to doctor Y, who may later hand over to doctor Z, or Doctor X, or whoever is walking past. Doctor X basically says something like "Cubicle fifteen has a fifty eight year old woman with three days of abdominal pain, mild fever, looks like typical cholecystitis, I've taken bloods, should be back soon, if they're okay she can go."

Theoretically this should be good. But it relies on Doctor X, and on occasion Doctor X doesn't know his arse from his olecranon.

As happened the other night. I turned up, grabbed my coffee and a computer and slumped in front of the terminal. I usually turn up a few minutes early to the dawn shift just in case there's some disaster, but this time there wasn't, so I picked up thirty three year old woman, post-seizure, did a fairly quick workup (post seizure is easy) and fell into my chair for the handover.

The two I got allocated were an old man with a DVT ( a blood clot in deep veins of the leg) and a woman in her forties with "possible meningitis". Everything needful had been done, I was assured, the CT scan was booked for seizure woman, the ultrasound was booked for leg man. Then we're half way through handover and some guy gets hold of the portable ultrasound and checks leg man's pulses in his leg and he doesn't have any.

A brief diversion here: you have arteries and veins. Arteries carry blood from the heart to the body, that's what you feel when you feel your pulse. Veins carry blood back from the body to the heart. A blockage in a vein, like a DVT, is serious, but unless it occurs in a nasty place (like the lung) is not of itself life-or-limb threatening. A blockage in an artery is bad news for whatever is down-stream of the blockage - heart (a heart attack), brain (a stroke), kidney... or leg.

This bloke had a blockage in the big arteries of his leg. That meant that his blood was not getting to his leg. Without blood the affected organ dies, and this was the reason for his cold, immobile, pulseless, blue leg, and the reason that instead of having an injection and a cup of tea and being sent home, he was going to have to be transported to the Royal to get his leg chopped off.

Grim news indeed.

And then the other woman who had "possible meningitis" came back with a white cell count of thirty (i.e.: was incredibly sick) and tried to get out of the bed, wrestling with us while delirious and fecally incontinent, and had to be intubated and so on.

The disturbing thing was this woman's family had bundled her off to bed last night when she was drowsy, incoherent and in considerable pain, and when the infection (whatever it was) was already raging though her. If they'd got her to hospital earlier she would have had less chance of brain damage.

The meninges, by the way, are this wrapper around the brain and spinal column, when they get inflamed you get meningitis. Meningitis can be aseptic (not caused by a virus or a bacteria), viral or bacterial. All of the forms are nasty but baterial is usually the worst and I suspect this was bacterial.

The reason they had bundled her off to bed with bacterial meningitis was "she was always like that". One of those "the slightest cough was pneumonia" people. Histrionic.

I don't know about all this. She would have been fairly unwell. Fever, deeply confused, in considerable distress. Surely someone would have noticed.

Now may be the time to reveal my universal law of human behaviour, which has served me well throughout my life:

If you hear something unbelieveable, and the only reason you can't believe it is you think "nobody could be that stupid", or "nobody could be that cruel", then what you heard is probably true.

There you go. Try it, it works.

Anyway, bedtime.

This friend of mine, arguably the smartest emergency doctor I have ever worked with, likes to have a can of beer or two after night shift. This was night shifts at Shipman, the House of Death. He reckons it's great to sit out on the verandah, singlet and shorts, stubby in hand, at eight in the morning and smile at the drivers going off to work. One guy actually slowed down his car and wound down the window and shouted "Hitting the piss already? Get off your arse and get a job, you useless shit!!" and drove off.

No point me doing it, the only people I'd enrage would be the chooks.



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