Brand New Day

Hail,
And after a string of days in the low forties (don't know what that is in the non-metric parts of the world, but I think it's over one hundred), this morning the hot spell was broken. We awoke (late) to gusts of rain and a soft breeze coming in from the sea, and six new born baby chicks running around the back yard. Everything old is new again. The cats are affecting nonchalance, but everything that was dry yesterday is now soaked or slippery or speckled with rainwater, and today even the fish were hiding from the deluge.

If this was a musical I'd be swinging around a lamp-post and dancing.

Anyway. New Year's Day.

I had Christmas Day off from the ED this year, which means I pretty much volunteered to work New Year's Eve. And all went well.

I seem to be really enjoying work in the ED lately, so much so that I am starting to regret the six months off I will be taking. The whole "disaffection/dissociation/going through the motions" thing seems to have vanished, which suggests that it was a kind of cumulative exhaustion, a minor case of burnout rather than any deep-brain realisation that I should not do this job. However, I am really enjoying a lot of stuff, I've got a surprising amount of energy at the moment, so I am being a wee bit cautious.

But I will give the six months off a go, see how it works writing-wise and health-wise and marriage-wise, and we shall see.

So how did New Year's Day go?

Busily. I started just before three oclock in the afternoon, and fairly soon I'd seen a drunk punched in the head, a twenty eight year old man who had managed to bicycle and sunbake his way into acute kidney failure, a rodeo clown with a head injury, a confused Irish man with a kidney infection, a five year old child who had had some of the irritant fluid from a glowstick squirted into his eyes (and was a lot braver than I would have been), and a man who, I suspect, (shot of someone riffling through the Reader's Digest, cue stirring music), taught us all a valuable lesson about medicine.

Lawrence was a seventeen year old boy who was our only resus of the day. He arrived by private car (one of those times where someone drives up to the door of the ED shrieking "He's not breathing") and was pretty much dragged into resus, where I was nominally in charge. Initial history from his hysterical sister was that he had coughed, suddenly complained of terrible chest pain and collapsed, unable to breathe. No history of asthma, no trauma, no drugs, nothing.

He was a thin young man, wide eyed, unable to speak, high-flow oxygen and salbutamol hissing into the mask, barely any air moving in and out of his lungs), and as the juniors got the lines in we (me, the consultant, ICU, anaesthetics, med reg) felt for his Adam's apple, probed at his chest with our stethoscopes and conferred in quick, quiet exchanges.

"Exclude pneumo" someone said, and everyone agreed. A tension pneumothorax is one of the five or so common, potentially fatal causes of chest pain and shortness of breath. It happens when air gets in between the lung and the inside of the chest, through some kind of tear or rupture. Air gets in and can't get out, the lung peels itself away from the membrane on the inside of the chest, and the lung starts to shrivel and collapse in on itself.

It's mindbogglingly painful. It can cause great difficulty breathing. And if it's not fixed very soon, it causes the heart to shift over to the wrong side of the chest and the big artery from the heart to the rest of the body (the aorta) to "kink". Once the aorta kinks, you get catastrophic loss of blood flow to the whole of the body, and pretty much immediate death.

It's one of the few things that can kill a healthy young adult in seconds. It can happen spontaneously (or after coughing), especially to thin young men.

And it is something that every single doctor who works in the ED thinks about, something that they run through their head, thinking "Would I recognise it? Would I remember what to do? Would I be too afraid to do it?"

Because what you have to do is grab the biggest needle you can find and stab it into the chest, two rib-spaces down from the collarbone, above the nipple, into the lung. Air rushes out, problem solved.

Anyway, that's what we were all thinking. And that's what we were looking for.

I listened. I could hear a faint wheeze, (he had minimal air entry), and I reckoned the left side of his chest was quieter than the right.

ICU listened, he reckoned there was definitely less air entry on the right, not the left.

Anaesthetics said that the patient's chest movements looked unequal - as if one lung wasn't expanding. Probably the left.

Med Reg reckoned the patient's neck veins looked big - another fool-proof sign.

And I was poised there with a fourteen guage needle - the largest needle in the hospital - sheathed in my hand, (so as not to further alarm the young man with the oxygen mask who couldn't breathe), waiting for the Adam's apple to kink off to the side or his blood pressure to drop or him to go into arrest in front of me.

Anyway, by this time (which seemed like treacle-slow decades, but was in reality a very few minutes), the Xray came back.

No pneumothorax. We all stood about and stared at where it wasn't.

We re-Xrayed.

Still no pneumothorax.

And meanwhile, the young man started to get better from the salbutamol and oxygen we'd given him (everyone who could possibly have anything like asthma gets treated by me as if they have asthma, a remnant from that woman last year who died at Shipton). And more of the story began to emerge - how he'd had chest tightness and wheeze for a while, how he got out of breath really easily nowadays, how things had got a lot worse since he started smoking. And his sister suddenly said "My asthma's like that."

Well, a "valuable learning experience", as they say. Not the VLE where you have to go to the coroner, and in fact, one where my "God know's what's happening, give him a milligram of everything" approach paid off.

But I had been standing over him, needle poised, ready to plunge it into his chest - which, by the way, would have given him a pneumothorax.

I think the weird thing is how the four younger doctors there (me, ICU, med reg, anaesthetics) all "saw" something that this guy did not have. Had it not been for Dr Scurvy, the ED consultant, who reminded us that the kids blood pressure was good, his trachea was mid-line, he was not actually deteriorating before our eyes - I don't know. Maybe one of us would have jumped the gun, got in there before the Xray, been the quick thinking doctor with the big needle, caused the thing we were meant to be treating.

And the First Rule of Medicine:

When all else fails, take a competent history (admittedly, virtually impossible for a few minutes there). In the last resort, do a decent examination.

Anyway, off to see a prisoner on methadone, and responding to comments today, come Hell or high water.

Thanks for listening,
John