Roundabouts and Swings

Hail.
I had one of those days that made a good story the other day, something with inherent symmetry today, like a page out of a medical drama.

I came in early and things were tense, Dr Fang loping along the corridors with arterial blood gas results, the ICU consultant and the radioloogy registrar clustered around a CT, a whole air of dangerous instability, lightning about to strike. Amongst the new patients was a tall, clean-shaven man, strong-featured, and his beautiful, well-dressed wife, each in their sixties. Mr and Mrs Grave, the nurse said. Her sitting by the bed, holding his hand, him intubated, the corner of his mouth pulled down.

There was work to be done, and I started doing it, because apparently the retrieval team from the Royal was on its way. I gleaned as much as I could - sixty year old man, atrial fibrillation, warfarin, ceased it for a colonoscopy -

And here I will pause to translate - a man in relatively good health, who had an irregular heartbeat. The smaller, less important chambers at the top of his heart beat irregularly, and because of this he was at risk of getting blood clots in his circulation - if blood is allowed to slow down, it clots - and to prevent this happening, he had been put on an anti-clotting drug. He had, as per medical advice, ceased this drug a few days before his colonoscopy.

Colono- is colon, the lower bowel, and -scopy means to look, and it's pretty much exactly what it sounds like.

- anyhow. Our man had ceased his warfarin in preparation for this procedure, and a few hours ago had collapsed to the ground, unresponsive. He had been brought to us by ambulance, CT showed what was thought to be a massive bleed but turned out to be a malignant stroke, a blockage of one of the larger arteries leading to the brain that is rapidly fatal. We had kept him cold and there was desultory talk from the neurology registrar about craniotomy -

- another pause to translate. Cranoi is cranium, the skull, and -otomy is "hole", and in the simple, delarative language of medicine it is exactly what it sounds like. Craniotomy, the drilling into and cutting out of a largish piece of the skull, may or may not save lives in cases of malignant stroke, but in Mr Grave's case it was not really an option - even the most primal reflexes were gone.

Of four people who have emergency craniotomy, two will die, one will be severely disabled, one will regain independence - if they are caught early, if the stroke has not damaged too much of the brain. When you held Mr Grave's CT up against the light, the dark ischaemia and the bright blood and the distorted swollen architecture of nerves covered more than half the circle of his brain, like a moon eclipsed. When he came in the ED registrar had brushed his eyeball with a cotton wool bud - he did not blink. Everyone like this, in whom emergency craniotomy is performed, dies.

I should also mention that craniotomy may be amongst the earliest of the surgical procedures. There is archaeological evidence of craniotomies performed, with stone tools and stone-age medicines, from which most people subsequently recovered. The Incas apparently did fairly well.

So, once the senior neurosurgeon had clarified what we saw on the CT, the retrieval team was called off and the tenor of the room changed. Nurses, doctors, spoke in murmured tones, began discussing options. Mr Grave's handsome wife sat and held his hand, his cluster of blonde children and grandchildren sat with folded wings and bowed heads, his youngest grandchild sobbed.

Meanwhile I was called down to the ED to see the first of our new patients, a woman with paracetamol OD. When I got there, Dr Ravindran was trying to get blood from a shrieking five year old boy. He spoke in the information-dense way that doctors do when they are very tired, very irritable or very good.

"Thirty eight year old woman, nil previous, ingestion twelve to twenty four grams, minimum forty eight hours ago, nausea, vomiting, abdominal pain, GCS fifteen, nil jaundice, LFTs, BAL, screen and coags not back yet, NAC, bed six." He turned and waved an inflated glove in the child's face upon which he had drawn a smiley face*.

This translated into a very bad story. I went in and sat next to Mrs Bishwakarma. She was tearful, her face sheened with sweat, a vomitus bag under her chin, a thick plastic tube snaking into her bandaged arm from a bag of clear fluids. I asked her what had happened.

It was all very hard, she said. Her husband. He had thrown her out. He said he wanted a divorce. She did not want a divorce. Why did he want a divorce? He had changed. He was not the man she had married, he was not behaving like a good man. She had been thrown out of their house and now there was another woman living there, with her husband. What did he mean by behaving in this way? She did not want a divorce.

Half an hour later we had settled on, if not a story, a series of stories. She had taken one (or two) packets of paracetamol. She had thrown up immediately afterwards (or she had not). It was to treat her pain (which she said may have come after the paracetamol or before it). Her pain was so terrible, doctor. She had not known it would hurt her. She had. She wanted to die, doctor. She wanted to talk to her husband.

I looked at her eyes, that deep, dark brown, and couldn't see jaundice there. Grief and fear and fluctuating realisation that something is lost are not documentable clinical signs.

I called a nurse in and felt Mrs Bishwakarma's abdomen. Striae, maybe someone who'd had children. Pain in the right upper quadrant.

She wanted to go home, to speak to her husband, to ask him what he was doing with this other woman. Could I call him, could you, doctor, and make him come in and talk to her?

I said I would go and check the blood results, and I went out, came back, sat down. There was a baby screaming outside, and the sound of a nebuliser, and the occasional alarm of a monitor.

"The tablets you have taken have damaged your liver," I said.

Silence.

"Am I going to die, doctor?"

"I don't know," I said.

Another silence. Times like this, people hear one word in ten of what is said to them, and nothing of what is said quickly. But two days after the overdose she still had paracetamol in her blood, and her liver was inflamed, her blood losing the ability to clot.

"Can you call my husband?"

I nodded, and said as soon as we got her upstairs, we would try. I went out, rang the ICU, told them we needed the last high dependency bed. I sat staring at the blood results, then on an impulse rang the number she had given when the ambulance brought her in, left a message on the answering machine.

Anyway. We went upstairs and told Dr White, and he had just sat in with the family of Mr Grave and told them of the outcomes, it being not a matter of if, but when, and death probably within the day, and Mr Grave's widow had said that he had not wanted to live disabled, so that if we possibly could could we let him go, and that he had wanted to help people all his life, and was an organ donor, and what should we do about that?

And that brings us up to here. Like I said, there is a symmetry here. Because my suspicion is that Mrs Bishwakarma has suffered such damage that she will need a transplant, and it is my suspicion that Mr Graves will be dead by the end of tomorrow, and that we will have gained something that we have lost.

But it's a long way from being a perfect symmetry, because the mathematics are that Mr Grave's blood type will not be the same as Mrs Bishwakarma's, and the mathematics is that Mr Grave will die, and because of him someone we don't know will live, and that Mrs Bishwakarma will live another two to twelve days and then die.

Anyhow. I should return to my study of respiratory physiology, but I can't tonight. I am going to lounge with my wife and watch Grey's Anatomy (it's only season one and we've already had conjoined twins and a schizophrenic psychic - it's not looking good). I got a story published in an anthology today, held the book in my hand and saw my name on the back and on the first story, and I am feeling celebratory. So it's merlot rather than methaemoglobin tonight.

Fellow students of emergency medicine, do not do as I am doing, study and pass instead.

Thanks for listening,
John
*He'd drawn the face on the inflated glove, not the child. Just had to clarify that.