Sunday, August 28, 2005


Well, well, well.

What do I say?

What I reckon happens is your brain gets data - spots of light, the disturbance of a hair, a sudden change in temperature - and changes it into something else. What you have inside your head is a machine for turning data into stories. Stories that means something to us, important stories.

The spots of light become eyes staring from branches.
The disturbed hair on the forearm means a spider.
The change in temperature heralds supernatural danger.

That's how we're wired up. We take what's out there in the natural world and make it into something useful to us. We hammer and burn chunks of historical data into personal and communal legends in the same way we hammer and burn chunks of iron ore into surgical tools.

And why all this preamble?

Because I'm trying to write about last night, and at the moment, all I have is data.

Right. Some data.

Last night I was in charge again. This is the new order of things. Me and Pippi and Maad and a few others arrive separately on our allocated nights, ten pm, take handover over the next two hours ("And lastly, cubicle thirty-four is an eighty eight year old woman with three days of cough, sensation of fevers, malaise, who started vomiting today and the nursing home sent her in. Blood pressure was...." and so on) .

So I arrived and it was busy, but I had a good team. Stung by our recruiting failures from the Eastern States, some very bright spark decided to lure people from the UK to work in our ED. They arrived last week, doubtless following the promise of golden beaches and hours frolicking in the waves. Fortunately, shortly after they arrived a local resident was taken by a great white shark*, and anyway, it's bloody cold around here. So they've had nothing to do but work.

So finally the ED is relatively fully staffed, admittedly only in numbers, not in numbers of people at a particular level. The glorious world is come.

So, a good team, a very busy department, and all of the consultants seem to be treating the junior registrars like an endangered species - kind words, offers to stay back and finish off difficult patients, leaving late saying "call me if you have any concerns" - I felt like some kind of Lesser Spotted Goatnuzzler or something.

But come midnight, it's just us. Me and three of the English (oddly enough, at handover they were arrayed in some weird order - from the least knowledgable, who was small and blonde, to the more experienced: each progressively larger and more red-haired - as if that's what clinical medicine does to you in England. Or maybe like the main sequence of stars.).

And so that was the first half of the night.

But by four, things started to wear at the edges, and by five it had fallen to shit.

Prisoner in custody of police, head laceration, otherwise inexplicable photophobia. Photophobia is when you scream when someone looks in your eyes with a torch. You get it in meningitis, whether from disease, head injury or whatever.

Woman who only spoke Romanian, infection that had spread to her kidneys after surgery, blood pressure that wouldn't stay up no matter how much fluid we pumped in.

Forty year old man having a spectacular heart attack whom I never actually saw, treated by remote control and relayed messages.

Vomiting kid after vomiting kid, including the niece of one of the local psychiatrists, and the local psychiatrist had heard of me (in a good, "someone-who-worked-with-me" kind of way, not a "foaming-and-gibbering at the mouth" kind of way) and kept trying to ring through to the ED and ask me to jump his cheerful and vigorously healthy three year old up the queue ahead of the sick people.

Irritable renal transplant patient with his lungs shutting down, his heart failing, and his kidneys already gone, one of those cases where his heart needs less fluid but his kidneys need more and this particular drug will help this organ but knacker the next one and so on - and he was an irritable bastard as well.

And the frightening thing is I was only dimly aware of this all this time, because we were all in the resus room dealing with Mrs Tribulus, who came in and couldn't breathe.

This is where it all fell apart. This is the bit I'm having difficulty coming up with a story about. A lesson, a legend, a moral or something.

Mrs Tribulus had acute pulmonary oedema, APO. This means her heart was no longer capable of pumping her blood around her body, so the fluid was backing up in her lungs, filling them almost to the throat. If diseases truly were demons, as we used to think, this would be some pale, long-limbed thing that came silently into your bedroom at dawn and filled your lungs with foaming saltwater.

It's something deeply frightening for everyone - first and foremost Mrs Tribulus (cold, sweaty, becoming more confused, pale skin mottling) but also for us.

But of course, we're in control. We don't let it show.

Anyway, I did the needful, the basic stuff. Frusemide, to help her pee all the fluid out. GTN, to decrease her heart's need for oxygen. Pressurised air into her lungs. And it took us hours to get a line in her plump, cold, heaving hands, and she was so sweaty the ECG dots kept falling off, and ...

and she wasn't getting any better. She was getting worse. More tired. More slow. Heart-rate up at one fifty, only so long that can keep going. Confused.

But anyway, I knew what to do (even if I am still sometimes too slow in doing it). Call a code - summon anaesthetics, ICU, medicine, X-Ray, get things done. Because this woman needed intubation - the whole paralyse and plastic tube thing.

I'm going to skip the rest. How we called code blue, and no one came, and we called again, and no one came, and then a nurse came and said no-one could come, and I sort of realised in the back of my mind that things were pretty crap out there in the rest of the hospital. And then eventually ICU came, (and he'd done one term of anaesthetics a few years back, and I had done none, so that meant he was in charge), and how eventually anaesthetics turned up, sneering and muttering, and fixed up our deeply dodgy intubation, and fled again, and then ICU had to go, and that left me, with a patient partly sedated and inadequately paralysed, and instructions from ICU to use certain meds and not others, and a woman who kept trying to pull the tube out of her throat, and who wouldn't get her blood pressure up and her heartrate down or her CO2 up, and only using one medication, a sedative, that neither relaxed this woman's muscles or relieved her pain.

Christ knows how she, and we survived. Seven thirty the consultant arrived and all began to slowly become right.

Moral: I don't know. I shouldn't have been left with her, with two of the only three remaining drugs I had ever used in this situation prohibited. I thought I knew what to do, but I wasn't that familiar with the drugs I would have had to have used, and I had been told expressly not to use one of them when I brought it up, and so I was stuck. I am not trained in the management of the intubated patient. I wouldn't leave the anaesthetics reg. to manage a bloody heart attack.

I don't know. That was the worst situation I've ever been in at Florey. What do you do when they say "If you're out of your depth, call" and you've called and people don't come or give advice on how they'd do something (the ICU way or the anaesthetics way) and then leave? We kept calling codes and the anaesthetic guy (who was busy) didn't come. What do you DO?

Okay. Panic off. Start again in one hour. Use last hour to revise use of rocuronium, the medication I reckon would have solved all this. So that if this happens tonight, and if what is supposed to happen does not, I will at least be able to manage things our way.

Thanks for listening,



Blogger Benedict 16th said...

Do you think it might ever be like that for the consultants too?

Again sorry about your team, there are a whole heap of other teams I would have preferred out of the 8!

11:44 PM  
Blogger Foilwoman said...

I'm so glad I'm not a doctor. I'm also glad you and his holiness are doctors.

12:01 AM  
Anonymous Anonymous said...


from my point of view, if they left you with the patient, what they tell you to do with drugs. if they wanted the patient managed their way, then let them take the patient to their part of the hospital.

you are in charge in the e.d. YOU! not some fly by night anaesthetics reg, or some 'ICU crap-internal medicine trained because he could not handle the stress of an E.D.' reg. by all means, in a patient with chf, go ahead and paralyse them, sedate the shit out of them, put them on a vent, and run nitro until their BP gets to some semblance of normality. oh, and dont forget the morphine.

if they dont want the patient paralysed, they can let it wear off once they have the patient on their ward.

and always remmeber, in the words of the fat man, 'the patient is the one with the disease'.

6:02 AM  
Blogger Bronze John said...

I think part of the difference between me and the consultants, or even the senior registrars at the moment is they wouldn't have let it get to that.

See below.

I honestly tried to type "and good luck to Port Adelaide anyway", but each time I started I ended up aspirating bile and I couldn't see the keyboard because of this black mist of rage


9:28 AM  
Blogger Bronze John said...

And today I'm damn glad too (see next post).


9:29 AM  
Blogger Bronze John said...

Dear anonymous,
Firstly, I really like those old-school blues songs you came up with.

Back in the real world, you're right. Once I've had time to think about these things I come to the same conclusion you do.

It's a progression - two years ago whatever the Med Reg said was holy writ. Now it's his/her opinion. I'm getting so I can disagree, suggest alternatives, raise questions - see him or her as just someone like me.

Unfortunately I tend to retreat a bit when I'm stressed, which is with the unstable, complex, acutely ill patients. But the thing that makes emerge better than anything else is that's exactly the kind of patient we are trained to manage, and if we know little, you can bet med and surg and ICU know less. So gradually, I'm exerting more authority.

It's a pissoff when something like last night happens, but if I let it happen again, I'll have no-one to blame but me.


9:38 AM  
Blogger Benedict 16th said...

1) Gee Scube, er I mean anonymous, have I ever met you? You must really P*&% off some of those senior medical types around you! We should trade notes sometime?

2) BJ Thanks for the best wishes, but your lot should have done better with JC on your side?

3) And I think BastJoan? (MrsBronze*) has a point.

*although I expect her to get better than Bronze at the local show.

10:12 PM  

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