Saturday, September 10, 2005

Lies

Hail,
Another post, this one is being written as some sort of distraction therapy. I am senior in emerge tonight, and given the previous nights (33% brilliant, 33% so-so, 33% writing-my-resignation-letter-in-my-head, -while-this-woman-dies-in-front-of-me), anything could happen.

So, I thought I'd distract myself with tales of Shipton, in the Bad Old Days, when it was understaffed, under-resourced, medically backward and a regular contributor to pages one to five of the Daily Sackbut. Usually appearing in sentences along with phrases like "Minister admits..." or "Grieving Family tells of ...".

In fact, let me tell you about two separate occasions where we ended up on page three.

The first was Mrs Murrain.

Mrs Murrain was brought in by ambulance having been found by her husband (at about five in the morning), "difficult to arouse".

'Arousal' in the medical sense does not mean the same as 'arousal' in the normal person's lexicon, when doctors say someone is "difficult to arouse" it means "someone with a persistently decreased conscious state" - more or less unconscious. It suggests some serious problem in the brain. "Highly aroused" means angry or manic, it's a psych term.

When I worked in Aldkodja House (a geriatric psychiatric hospital), one elderly woman was brought in by ambulance with "a persistently decreased conscious state" and with a provisional diagnosis of massive stroke: it turned out she had fallen asleep in front of Passions, and woke up when someone tried to put a needle in her. She was pretty damn aroused by all that, I can tell you.

But Mrs Murrain (mid forties) was not asleep. She was in fact barely breathing - long, drawn-out wheezes, five or six a minute, not enough to keep her going at all. She had a Glasgow Coma Scale of about ten - which means any lower and we would have been looking at intubation. She smelt strongly of alcohol, she had recently been put on valium* for her depression and had been found with an empty bottle of valium and a bottle of sherry beside her, she was on morphine for some reason I can't remember, she has asthma and she had pneumonia. Basically, she had a lot going wrong with her breathing, and there was a chance it wasn't oxygenating her brain properly, and something needed to be done urgently.

And we did it. Big lines in either arm, high flow oxygen, I think we tried a naloxone infusion, chest Xray, bloods, some iv antibiotics...we pretty much did it all. Her husband was hovering nearby, looking frightened. I did my best to comfort him, once she was stable, and then, once there was only him and me and his unconscious wife in the room, I sat him down with his cup of tea, told him we were doing everything that could be done, that the worst had passed, and asked my one remaining question.

"I understand this is a very difficult moment for you" I would have said, "but there is one more thing I have to ask."

He would have nodded. Most people are desparate for something to do to help, and the faith they have in people like us at moments like this is crushing.

"And it's a difficult question, and I wouldn't ask it if I didn't think it would help to make sure we do all we can for your wife. Is it possible, even remotely, from what you know of your wife, that she took all those tablets and that bottle of spirits in an attempt to harm herself?"

He shook his head, and I pretty much let it be. Psych would be speaking to her later on (a few days later on, once everything acute was fixed up) and in the interim she owuld be staying in the hospital. But it looked suspicious, and people with chonic pain are at high risk of suicide, and she did have a nastyish pneumonia, which might
have pushed her over the edge...

Anyway, I handed over to another doctor, (Sarah, actually) and went home.

A week later Dr Shem came over to me. "Have you seen Mrs Murrain's letter?" he said.

"Nope" I said, "... she only got discharged a few days back, didn't she? Anyway, I could do with hearing about one of our successes. Let's have a look."

And he passed me this eight page letter of complaint, probably the single most vicious and bile-ridden missive I've ever seen. It did not mention me personally, it lashed at the medical, nursing, clerical and administrative personnel of the entire hospital. It described her recent bout of pneumonia, during which "events led to [me] becoming unconscious" (presumably the event of her taking all her medications and drinking a bottle of sherry). Suddenly, she wrote, ambulance men had bludgeoned their way into her home, terrifying her dog. They had dragged her from the "weeping arms" (her term) of her husband. She had been left lying in her own excrement while doctors and nurses laughed about her condition - to be honest, I wasn't that much interested in checking her underwear, I was trying to get her breathing. Her husband had been repeatedly harangued about her sanity, she had recieved no treatment at all, and once admitted had been badgered by "so called doctors" who made deeply offensive suggestions about her mental state and recent behaviour.

I remember staring at it, the thought forming in the back of my mind that technically every doctor and nurse and auxillary staff memeber in the ED would have to be called in to explain their behaviour, and wondering what the hell was going on. I had heard of post-surgical psychosis, was this it?

"She did this last time" said Shem. "Knee surgery with Dr Chisel. Tried to have him struck off - but that was only a four page letter. One angry woman."

"Jesus" I said. "Can't please all the people, I suppose."

And the next day it was page three of the Sackbut, and a picture of her standing, arms folded, scowling, out the front of the ED, and a ten second space on channel Ten, and the radio, and so on. More "Shipton, House of Death" stories.

And two weeks later, two weeks, I tell you, a small paragraph on page 67 about how the Ombudsman had investigated it and found we had no case to answer.

That's case one.

Case two was very different. in the back of my mind as I write the idea is forming that I am writing to calm myself down before night shift, and that these events are not the most calming selection. In fact, this last one still frightens me, and it, more than any other single presentation, has changed the way I deal with a common disease.

Nine oclock, Shipton, ED. Changeover had happened fairly recently, so we had new staff on, many oversease trained. I was relatively junior at the time, second/third year out or so, and luckily there were two more experienced doctors on as well.

But none of the experienced doctors knew about Jessica Cesious.

I was standing in cubicle G, talking to Mrs Termagent, an irritable elderly woman who had suddenly become dizzy.

"I think" I said, after listening to her story and having a good look at her, "that you have vestibular neuronitis".

She bridled at the very suggestion. "I do NOT!" she snapped. "I'll thank you to show -"

From several cubicles away I heard a woman's voice, a choked kind of voice. "I...can't... breathe" she said. It was the second time I'd heard her say that in a few minutes. I held up my hand. "I'll be right back" I said, and fled the cubicle.

I tried to follow the sound. Four cubicles away I came upon a room with a terrified looking young woman in a bed, a nebuliser mask on her face, hissing and billowing. She looked pale, and sweaty, and she was shaking. She looked at me again and said "I... can't...breathe." There was no doctor with her.

I walked over to her and put my stethoscope on her back, saying "Don't worry, you're going to be alright." I think maybe because I had done a lot of psych, and I was junior, the thing I was thinking as I walked across the room was that this was someone who was panicking because of her asthma and the ventolin. As I walked my vision widened, there was a terrified looking nurse standing by the side of her, holding a sheaf of notes.

I moved the stethoscope over her broad, pale sweaty back, where we listen for the movement of air in and out of the lungs. Her asthma wasn't that bad, I couldn't even hear a wheeze... Oh my God.

I turned to the nurse, and she said "Asthma. She's saturating 76 percent."

I looked around. There was noone else there. She had no line in her arm, no venous access at all. And she was obese, and sweaty and shut-down, and starting to panic.

"Get Meri" I said, because Meri was the senior doctor on. "Jesus" I said, grabbing a jelco. "Has she had prednisolone?"

The nurse shook her head. I got a line in - which took one valuable minute, but at that time I couldn't - I still can't - deal with very sick people who don't have venous access, because if it all falls to shit, you can't do anything without a line.

She looked no better, she looked worse. We wheeled her into resus, she still looked bad. No seniors had arrived, the nurse was still running from corridor to corridor looking for them. I called a code blue, the first time in my life I had ever called
an arrest code on someone who was still breathing, and asked for some adrenaline to be drawn up while I tried to get a second line in. By this time she was confused, twisting her pale, slippery arm around in my grip, making the difficult and necessary impossible.

And as the rest of the doctors came into the room, she stopped breathing, like her lungs had turned to rock, and hurled herself back onto the bed, suddenly a deep dark blue. There was no pulse. I started cardiac compressions while everyone else started resusciating the dead woman. Probalbly the only time in the last few hours that oxygen was moving in and out of her lungs - that's why her chest had been silent, because she was not actually breathing when I listened to her back and was for one second reassured. And we worked for an hour and a half until the retrieval team from the Royal arrived, and they took her away, with her husband and two toddlers following the ambulance, numb and silent.

And a few days later they turned off the machine, when the scans confirmed massive hypoxic brain damage. And thank the good God that she died, or she'd still be there.

Anyway, that was among the worst things that had happened at Shipton in a year or so. We had completely failed to recognise the very clear signs of a common killer - particularly her oxygen saturation. If any of my readers smoke, they are saturating at 99% - the blood in their arteries is 99% oxygenated. Anyone else should be 100%. Asthmatics who are very unwell reach 95%, those who are about to die may drop to ninety. This woman was seventy six on arrival - by most counts already dead. We had failed to help this woman, our inaction and mismanagement had robbed her of her only (admittedly very very slim) chance of surviving this attack.

But the nurse was new, and was doing a long shift, and had many patients to look after.

And the treating doctor - had he known? Dr Sutekh was not particularly bad, but he was junior, and not familiar with the modern Australian treatment of this common disease. He had only recently arrived in the country, he was still finding his way around - ideally he would have been supervised, but if the senior doctors are supervising, who sees the really sick people? He knew asthmatics require ventolin, but he had not seen a case this advanced. In later conversation, it seemed he had not previously regarded asthma as a killer.

The coroner's inquiry seemed to blame systemic, rather than individual problems.

Anyway, if I know one thing in medicine it is asthma is a killer. Years later, the sound of someone wheezing still at some level frightens me. Asthma and diabetes: in my darker hours I think that for the vast majority of people with even moderately severe forms of these diseases, there are two options for people. You control the disease and you live a long, happy and normal life. Or it controls you and you die in your twenties or thirties.

And when I dragged myself to work the next day (everyone shell-shocked, whispering in corridors, one of the worst events in Shipton's recent history), someone handed me the Daily Sackbut.

"Woman dies to give life to many" read the headline, or something similar. And it turned out that Ms Cesious was an organ donor, and because of her, three people lived who would otherwise have died, and several of the blind could see, the halt could walk, and the weak were again made strong. There was a big picture of the late Ms Cesious's husband, and her two toddlers. And underneath, that bit of the article they extract and print up in bold as sort of a sub-heading, was a quote from him. "The doctors at Shipton were marvellous" he said. "They did everything that could possibly have been done. I'd like to thank them, and I know Jessica would too."

So, that's why I don't read the Sackbut to find out what went on in any widely publicised case. Come to think of it, I don't watch the news at all anymore, haven't since about nineteen ninety. But anyway. Nine thirty approacheth, time to struggle into the shower and get ready for tonight.

Funny, despite all this writing, I don't feel at all relaxed. Wonder why that is? How daft am I?

Thanks for listening,
John

*Satan's jellybabies. Seriously, valium/diazepam/antenex/etc., is a highly addictive drug that has no place in the long term treatment of anything, and very few short term indications at all.

7 Comments:

Anonymous Camilla said...

Some people have the quality of Grace, and others don't, I guess. That second story blew me away.

10:18 AM  
Blogger Chade said...

You know, with the current surge in Medical Drama for the TV. You could turn many of these tales into an excellent script. Hell, put two stories together, create an interesting cast and pitch it. I'm thinking it would fit with a SCRUBS type of thing. heartwrenching and humourous (if only because if it wasn't you'd jump out the window.) By the by, I'm going to email you soon. I need an assist with a scene and I need to know medical speak for it.

10:45 AM  
Anonymous Anonymous said...

Hiho there, mr anonymous again.

What a great two stories.

ALLOW ME TO ADD ONE THING
(SCREAMING AT TOP OF LUNGS)

INTUBATION!!!!!!!!!!!!!!

all praise the tube
the tube is good
the tube is right
we love the tube

why?

because a happy patient is a..

(say it with me)

INTUBATED SEDATED AND PARALYZED PATIENT

really, the second lady should have been intubated when she failed treatment number one. steroids are shit for acute asthma, they take a few hours to work.

push the ventolin
push the atrovent
push magnesium

if that does not work
push the tube.
and hope to god youc an get her on a vent with alarms set high enough to do her any good. and if you are doing that anyway, then sterids every 6 hours are appropriate.


probably should have done it in patient one.. just to really give her something to complain about. it is justifiable with an overdose anyway.. protect the airway, push the charcoal (dont know what else she might have taken, right).. get drug screens and a foley.. then laugh at her behind her back :) while you are putting on the four point leather restraints.


anyway, dont know that you should really beat yourself up over this one.. it was the other doctor who did not recognize it.. really, anything in an asthmatic down to about 92 - 90 is acceptable, below that, get worried, and at 75 w/ 100%02.. get ready to put her on the vent.

I had a similar case, but with a dude with CHF.. 500lbs at the age of 24.. CHF with multiple admissions, noncompliant with meds, came in with DIB, walking, talking. was brought to the trauma bay, and just as we were about to ask him his allergies, he went flump. terminal flump in this case. over an hour of resuss.. intubated within the first 60 seconds, probaly sooner. cp, central lines. dopamine, epi, the full run, including an isoproterinol drip (I have never used that before).. in the end, it was all for nought..

the moral being that despite your best efforts, sometimes the patients just have disease that is hard to fight. especially if their main probelm is not enough o2.. sometheing we would all be hard pressed to live without.

BTW - great blog, is now my required reading. I am now thinking of signing up, just to get out from under the anonymous label.

keep the faith, bro.

12:24 PM  
Blogger Bronze John said...

Thanks Cam,
I think it blew pretty much everyone away at the time, nowadays if I say "the woman with asthma at Shipton two years back" everyone still knows who I'm talking about. Thanks for reading.

John

6:13 PM  
Blogger Bronze John said...

Hail,
Come back soon. Interesting idea about the script, I worked out one day a while back that this blog stood at 66 000 words, and it'd be closer to 75K by now. Halfway, maybe, to a book.

Email away - hope I can help.

John

6:15 PM  
Blogger Bronze John said...

Hail a&eonymous,
You're right about the tubing. That's the single biggest difference between where I work now (Florey) and where I used to work (Shipton). At Shipton (not accredited for training, run by career medical officers and GP trainees) intubation was something other people did to practically dead people, at Florey (accredited for emergency medicine training, run by consultants), it's just part of our treatment options.

I think the first woman was intubated briefly, once she got upstairs.

The second woman certainly should have been (well, she was certainly transferred intubated). One thing I didn't get across was how brief my role in the second case was - less than five minutes between my going looking for her and my calling the code.

Anyway, thanks for the advice. Some of your acronyms we don't use - what's DIB?

This will all be a lot better once I've done my anaesthetics term, 2007.

6:27 PM  
Anonymous Anonymous said...

DIB = dificulty in breathing - C'mon, you KNOW this stuff - remember TIN-CAN-BED-DIP?!?

Seven years down and I still shit myself with the real sick ones (although exterior icy calm). BJ, you mention needing an IV - remember A for Airway and B for Breathing come before C...and if all else fails and you can't get access, there are a few novel routes..,

- Cutdown
- Central access (You'll have done a few of those by now I hope)
- and, as I once infamously proved at a wellknown Southern suburbs tertiary centre, there is the intracopororeal route - y'know, in the moribund obese male with NO access, consider popping a short, fat jelco into his, ahem, short and fat appendage - the corpora cavernosa communicates with venous system - kinda useful route to the circulation althought the intensivist who walked into the resus looked at me a little askance...,

Not sure if you should put adrenaline in this way though ;-)

Keep smiling...

6:32 AM  

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