Wednesday, June 13, 2007

The more ICU, the more I want you

And herein a bit about bad doctors and bad luck.

First, the last. There is a man in bed eleven - have I mentioned how everyone who goes to bed eleven dies? Have it tattooed on your chest - not for bed eleven, Florey ICU - about whose case everyone who works in the ICU, every nurse, every doctor, knows. I have spoken to his relatives in Sydney every day, have sat with his sisters and mother, Dr Fang knows what ventilator and dialysis settings he is on at any time, and how much of what is flowing into his veins, Dr Black contacts the hepatologist and the infectious diseases specialists every second day.

This is because he is far and away the sickest person in the hospital, and also because of what happened.

Mr Steed came to us with sepsis - an overwhelming infection that had started in his veins and spread throughout his body. He was a man with a long history of IV drug use who had recently holidayed in Thailand. He had started feeling unwell a few days before takeoff, concealed the fact, deteriorated en route, almost died on the plane home.

When they brought him up to us he was rain-coat yellow and delirious, in multi-organ failure - a massive infection in his lung, growths on his heart valve that frequently broke off and whirled downstream to occlude the blood supply to his brain, kidneys that were shutting down and a liver that has all but ceased to function.

Depending on how you look at it, that was up to five organ systems in crisis - liver, lung, heart, kidney and brain. We put the tube down his throat to help him breathe, pumped him full of chemicals to make his heart pump, hit him with multiple antibiotics and some uber-anti-inflammatory stuff that costs twelve and a half thousand dollars a vial. For the kidneys we did dialysis.

(For the brain and liver, nothing. There are artificial hearts and basically artificial kidneys and machines to help you breathe, but the liver, bat transplantation, and the brain are essentially unreplaceable. Apparently some kind of pig liver thing is on the way).

The lungs were really the only ones we could do a lot about at the moment, so we put in a chest tube - you paint the side of his chest with disinfectant, inject some anaesthetic, make a cut with a scalpel big enough for a couple of fingers and poke a long thin plastic tube into his lung to drain the pus - in the hope of opening up his lungs again.

Unfortunately, we hit his spleen instead. It's just below. The spleen is full of blood, he bled three and a half litres - close on a gallon - in under a minute and had to be rushed off for emergency surgery where they removed his spleen entirely.

Apparently - this all happened when I was away - the responsibility for the error will be shared between Dr Black, who put the tube in, and the ultrasonographer, who marked where it should go. Both are from southern India. Dr Black is about forty, one of the most impressive doctors I have ever met: deeply compassionate, extremely competent, fantastically knowledgeable.

I realised last night that if I was asked how Dr Black looked I would probably say he was good looking, because he is such a good person and is very good at his job. Whereas if asked about the ultrasonographer, I would say she seems like a good person, and was probably good at her job, even though I have only seen her once and have never spoken with her or worked with her - I would say she was nice and competent because because she is very good looking. That's the level my brain works at. Good people seem beautiful, beautiful people must be nice, everything smudged.

Anyway. Since I've mentioned a very good doctor, a bit about a very bad one. I don't know if I've mentioned Johnny Knuckle before. Dr Knuckle is one of the five or so truly bad doctors I have met. He graduated from medical school after nine years of a six year course, starting out two years ahead of me and finishing one behind. When I saw him he was on his third attempt at intern year - still unable to work unsupervised twelve years after starting.

He worked with us at Shipman, in the ED, the last year I was there. One time, during a moderately unbusy session, I was sitting at the desk educating the medical students about football and he asked if he could ask my advice.

"Sure," I said, wary.

"I've got a patient who was eating at an Indian restaurant when his tongue swelled up and he wasn't able to talk..."

"Can he breathe?" I yelped, half-rising from my chair. The most emergent problem in this case is anaphylaxis, a severe allergic reaction where the mouth and tongue swell up and can block the airway.

"Don't worry, I've already given him adrenaline, that's all okay," said Knuckle. Adrenaline is the appropriate treatment for anaphylaxis - he did get that right.

"Okay," I said.

"But I was wondering if he needed a CT head?". This is what we used to call a cat scan, basically an X-ray on steroids.

"What for?"

"To chack if he was having a stroke."

"Does he have any signs or symptoms of a stroke?" I asked.

"No," admitted Knuckle.

"Well," I said, pleased at my own wit, "he may be having a stroke. I may be having a stroke, you may be having a stroke. But until he shows signs or symptoms of a stroke, no CT."

"No CT?"

"No CT."

I finished up and went home. Two days later I went back and the place was in an uproar. One of the seniors grabbed me as I came in. "Did you hear about Knuckle?"

"What now?"

"Some guy collapsed in an Indian restaurant, face like this, arm like this -" and here Dr Porcino imitated the profound one-sided paralysis and facial droop of a man with half his brain's blood supply cut off - "and Knuckle gave him adrenaline and nearly killed him!!!"

Anyway. Sarah reckons I have written this before, or maybe it's just because I've told her so many times before. Praise God, Knuckle was as crap at documenting as he was at other aspects of medicine and had not written "discussed with Dr Bronze" in the notes.

Any medical students reading this, take note. If anyone askes your advice, do not just give it, especially if the person asking your advice has grade IV (malignant) stupidity or end-stage ongoing bafflement or however these things are measured. Go and see the patient. Otherwise it's as legally defensible as other forms of diagnosis by hearsay.

Anyhow. More on this later.

Thanks for listening,


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