Monday, July 25, 2005

Big

Have finally calmed down enough to write this. Things have gone badly today, they may yet go worse. We may have to revise that previous number of fuckups.

Okay.

A few days ago the ambos brought Mr Baruch to us from Ratbite River, one of the smaller local hospitals. We got this phone message and apparently it said "forty eight year old man, low-speed single vehicle MVA, mild lumbar pain, no injuries observed, HR 80, RR 12, BP ?, neuro intact, unsuitable for Ratbite." So someone who had had a very minor sounding accident and sounded completely well (except for the missing blood pressure) who was being transported in an ambulance to the local trauma hospital.

I sauntered out later on and I saw why he was unsuitable for Ratbite. He weighed, by his own estimate, at least one hundred and ninety kilos. That's around four hundred and twenty pounds.

Mr Baruch did not have a particularly good time of it. Ratbite couldn't handle him, apparently, because they had no beds strong enough, and both they and the ambos were unable to accurately measure his BP, because no cuff would fit around his vast arm. And they had intended to Xray him but he would not fit on their Xray machine. So they sent him to us.

Anyway, what was going wrong? Mr Baruch was unwell. He laboured when he breathed. He had great logistical difficulties when he needed to go to the toilet. His heart was staging a tactical retreat from the impossible task it had been set, pumping blood around a body that occupied a good few hundred litres. His legs had hardly any circulation, he had chronic ulcers. And he'd had a car crash which, although it was low speed (how fast can an old Astra go in reverse with a one hundred and ninety one kilogram man in it?) involved considerable forces - the seat had snapped in half when he reversed into the tree.

He hadn't done any harm in the actual car accident, and I tried to explain the situation to him. We can't send people home if they can't cope at home. His wife (sixty kilos max) and three slender daughters were not coping with him. I reccomended him for admission and went home.

But - and here's the turning point - I didn't do any blood tests or Xrays. We don't normally do them for every low-speed car crash, like we don't do chest Xrays and CT scans for every twisted ankle. And he'd been worked up by his cardiologist less than two weeks ago, blood tests and chest Xrays normal, and his shortness of breath was unchanged in the last few months, and his ulcers were pretty much the same as they had always been, and he hadn't even hurt his back to any great extent. One small abrasion on his shoulder and that's all.

Anyway, home again, home again. And I saw one of the nurses a few days later and she said that Mr Baluch had not been admitted, he had been sent home with home nursing. And I suitably chastened, because I hadn't really thought of that, and that was that.

And today I arrived at work and found out what had happened.

The nurse had gone to Mr Baluch's house to dress his bandages, toilet him, etc.

As part of her normal workup she had done a blood test. I don't know if he looked better or worse at this point, I pray he would have looked sick but I fear he may have looked like he did when I saw him.

She had found he was in acute kidney failure.

He was sent to Florey, and more blood tests and a chest Xray were done.

We found he had an overwhelming infection in his blood - a white cell count of thirty five point five, three times normal.

He was admitted upstairs. He deteriorated rapidly.

He was transferred to the Royal. The transfer team arrived.

He went to the Royal, where he was intubated, sedated and paralysed and a tube stuck down his throat. He is unconcious, fevered, comatose. A sinister rash has appeared on his chest, great swathes of his skin are scarlet and indurated with infection. The ulcers proceed unchecked, they pump drugs into his blood to make his heart beat faster. Adrenaline, the fight-or-flight hormone, to push his fat-choked heart into one final desperate sprint before the finish line.

The prognosis is "guarded", according to the Royal. That means in the most highly supported hospital in the state there may be nothing that can be done. And he doesn't only have to get well, he has to get well enough for the stomach stapling/liposuction that he is lined up for. And that's sizeable surgery.

Now, my part in this. I saw him, I didn't do blood tests. He was sent home. Two days later he was very sick, three days later he was intubated. Which ever way you look at it, this is very very bad.

There are escape routes (for me, of course. Not for him). I handed over to someone senior who saw nothing that I didn't see. I recommended that he be admitted, I didn't want him sent home. I followed, to a certain extent, the protocols. I documented that he felt no worse (except for a bit of back pain) than he had done in the last month.

But in the end, I looked at him and didn't see acute renal failure and sepsis, I saw what he told me was the problem. It may well be that he wasn't that sick when I saw him - the district nurse said he was angry at being discharged from the hospital, and that he seemed determined to prove that he could not cope at home and thus jump the queue for the surgery. I tell myself that I cannot have missed a white cell count of thirty five point five.

But I don't know. We shall see - and by we I mean you too, don't think I won't be ringing up the Royal every few days. And I've changed what I do as a doctor - I have added extremely overweight people to my list (the very old, the very young, the mentally ill, the immune dificient) of people who may well be much more sick than they appear. In a few weeks I will be doing my "interesting patient" presentation, and it's always an opportunity for ritual flagellation.

And lest anyone think I wanted this man admitted to the hospital because I am a soft touch for people who pull at my heartstrings, it should be pointed out that he was a difficult man to feel sympathy for, in that he was an irritable man: whining, entitled, condescending, blaming everyone in the room for his problem except in any way himself. It might well have been a protective mechanism to help him deal with what he had to deal with, but if the truth be told he was a miserable, unpleasant son of a bitch.

Anyway. We shall see. Thanks for listening. Off for red wine and Doctor Who DVDs.

John

6 Comments:

Blogger Benedict 16th said...

Bugger!

Hey John, why does it feel like an Elephant sitting on my chest, and Jeez my left shoulder aches. And this thirst lately - it makes it hard to eat my chocolates, without having to swig some coke. Then the coke makes me so gassy I need my acid suppression meds, oh well if I have another block of chocolate, I can balance it by taking 4 metformins instead of two.

I suspect the fellow had made more choices about his impending renal failure and sepsis than you could have. What was his BSL anyway, the triage nurse would have done one, wouldn't s/he?

If I could post images I would, but check out this from the Placebo Journal, a new medication Godivaphage

10:43 PM  
Anonymous Anonymous said...

Hi BJ (no pun intended)

You are overlooking the most important fact, you work in an emergency room, and you are NOT an internal medicine doctor. the focus is different. Bugger his size, bugger the ulcers and bugger the rest of it, he was a man who was status post MVC, you worked him for that, saw no injuries and let him go home. It is not your job to catch every last little thing that might go wrong with a patient, that is why you are a emergency physician. You job is to deal with the emergencies. I am sure that if he had been complaining of renal pain, poor urination, uremic frost, or any of a dozn other things you would have done the tests, but he wasnt, you didnt, and now the problem has been caught by a primary care provider, whose job it is to provide, hello, primary care.

Take this for what it is, somebody with a deeper problem, presenting for a minor one, which you dealt with. You should have no guilt because you didnt look at him and see what was going on, if he was not even complaiining of the symptoms.

1:09 AM  
Anonymous Anonymous said...

Oh, and dont forget, it was not even you who sent him home.

1:10 AM  
Anonymous Camilla said...

What anonymous said.

12:28 PM  
Blogger Foilwoman said...

Your holiness: Is Godivaphage available by prescription in the U.S.?

5:27 AM  
Blogger Foilwoman said...

I'm so slow. I love Dr. Who. Yet when I read the final sentence of this post, I spent some time trying to find "The Doctor Who DVDs", which must be an interesting new medical series, since Doc here (or HWHIOBC, He Whose House Is Overrun By Cats, according to His Holiness, or HH, for those with my acronym creating mania) is watching it. Which Dr. Who do you like best?

5:40 AM  

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