Tuesday, September 18, 2007

Lightning strike

Got my results from the college today. They included an analysis of the exam I failed - I passed the viva and got fifty seven percent in the multiple choice. Unfortunately the pass mark was sixty. Each multi choice quesiton is worth one and a half percent - I failed by two out of ninety questions.

Such is life. It was probably two of the endocrine ones. But I passed the hard one.

Anyway, I am writing to you today with covered in a faint, bronze-coloured sheen. Because it's a hot day, I've been out hitting the punching bag, and for the last two days I've been taking rifampicin, which, the advisory sheet says may cause "discolouration of bodily secretions". So currently, I sweat a yellowy-orange colour and, were I to be moved to tears, I would cry a yellowy orange colour.

Bronze John indeed. However, on the good side for the next few days I have probably got additional protection from leprosy.

This is all because of Nyssa Menninton. Nyssa had been brought to the ED by her mother a little over a week ago. Her mother had went around to her house and found her slumped on the floor, unrousable, having lost control of her bladder and bowels. She brought her into the ED. ED found her cold, drowsy, battling an overwhelming infection of some kind*, and with a blood pressure so low it could barely be measured.

However, she was young, and otherwise fit, and she resonded well to initial therapy, fluids and antibiotics, so she didn't go to the ICU, she went upstairs to the medical ward.

It's difficult to reconstruct entirly what went on in the medical ward. Some of it is relatively clear - there was an Xray taken on arrival, it appeared normal, there wasn't another one taken later on. There was a single urine culture and a blood culture - both were clear. She was treated as if she had an occult infection and put on some relatively high grade antibiotics. Much mention was made in the notes of her poor self care, her head lice and her toenails, and her unco-operative attitude. Less mention was made of the fact that no-one ever found out where this infection was coming from and thus what antibiotics were best for it.

One week later she was discharged. The medical entry on the date of discharge reads in part "white cell count twenty one, bicarbonate eleven and falling" and then notes she was discharged. The medical discharge summary, were it to be translated, would have to read "Ms Mennington was found almost dead. She clearly had a life-threatening illness. We don't know what it was. She's still very sick, so we've stopped on of the antibiotics and we're sending her home. A nurse will check up on her in a week."

I am aware of this because regardless of the outcome of this admission, someone is going to be called in to explain this.

Nyssa Mennington went home where she continued to deteriorate. At two in the morning her mother checked her for a rash, it wasn't there. At eight thirty she was cold, blue around the lips, still speaking but seeming confused. Her skin was covered in dark purple stains, irregular around the edges, as if she'd been dabbed with cotton wool. Don't click on this if you are easily upset (if you are, here is a less distressing image of purpura). When the ambulance arrived (less than two days after she left) she was breathing fifty times a minute, body temperature low thirties, blood pressure was again undetectable.

Anyway, we have done everything we could. Pumped her full of fluid and antibiotics. She has bilateral pneumothoraces - her lung has collapsed on both sides. When we Xrayed her her left lung had come away from the inside of her chest and collapsed to less than half of its normal size, and this meant that her heart and aorta were being pulled over to the right side of her chest. I painted the side of her chest with disinfectant, injected an inadequate amount of anaesthetic into her chest (between the ribs on the side) and we poured opiates into her veins while I cut through skin and muscle, felt my way though fat and pleura and pushed my gloved finger into the space where her lung was meant to be. Instead of the rising and falling of the lung there was profound** emptiness, so I asked for the chest tube - the slim, plastic tube we were going to push inside her chest to let the air out.

That's were things got a little weird. Every time she breathed in there was this sucking, farting noise, and bubbles formed, and when she breathed out, fluid came out.

The air coming in was sortof expected. I tried to stop the air getting in - air getting in would push the aorta (the huge artery that carries blood out of the heart to the brain and the rest of the body) and the heart further over to the right, the wrong side of the body. if you pushed the aorta too far it would kink, the heart couldn't pump blood out, there would be sudden, massive heart failure, and Nyssa Mennington would be dead with my hand inside her.

The fluid coming out was another matter. I slid the tube in and she coughed. Some fluid spat out of the hole in her chest. A small amount, maybe a mouthful, of what we call serosanguineous fluid - clear fluid stained with blood.

"Nasty" said one of the ED doctors. "Big infection"

She coughed again. A larger amount, maybe a cupful.

"This often happens" said the ED doctor. "Stictch it up."

She coughed again, and straw-coloured fluid with clots of blood in it hissed out. It squirted over the floor, flooded the bed, spattered my gown. I stared through my facemask.

"Hmm" said Dr Umesh. "I've never seen that much before."

Nyssa went into a coughing fit. With each cough fluid vomited out of the hole I had made. Dr Umesh took over in time to have his facemask spattered with blood. He drew the tube back minimally.

"I wonder what else this could be" he wondered aloud. I ran through the possibilites -

"Ladies and gentlemen of the jury, you have heard how Dr Bronze, by his own admission, inserted the chest tube not into the lung, but into the abdominal cavity of the deceased - "

"So, putting a chest tube into the spleen - that's a common mistake. She may have had slightly unusual anatomy, and I'm sure you took that into account. What are the primary anatomical relations of the spleen, anyhow?"

"I'm terribly sorry, Mrs Mennington. During the procedure, the tube entered - I put the tube - accidentally - into Nyssa's heart."

"Mate, buy me anuzza drink - another drink and I'll tell you about when I used to be a doctor - until I put a chest tube into someone's brain."

She continued to cough, and fluid continued to gout out. I asked for the gelfusin to be turned up - not that it would do any good in the short term, but it looked like I was doing something - and Dr Umesh, radiating calm, continued to withdraw the tube micron by micron until she stopped.

"Hmm" he said. We went and got an Xray, which showed that we had not pierced the heart or the brain, and in fact had put the tube pretty much in the right place. It was slightly ambiguous on the matter of the abdomen - it did not rule out the possibility that I had somehow gone in through the lung, then withough noticing extended my finger ten centimetres and shoved it through a big sheet of muscle into her abdomen. However, considering the chest tube was behaving exactly as if it was in the right place, and the patient seemed better, rather than worse, and her heart was now in the right place, and we were getting air, not peritoneal fluid out of the tube, I began to relax.

"You worry too much" said Dr Umesh "It's no big deal." Dr Umesh had not been there a few months ago when Dr Black accidentally put the chest tube into the spleen.

Anyhow, we took Ms Mennington upstairs. We still don't know what is wrong with her. Currently we are treating the two pneumothoraces as spontaneous, which is unusual in someone of her build, even a smoker. We are treating the low blood pressure, the high fevers, the rash as meningococcal sepsis - hence all possible contacts have been given antibiotics that turn their tears and sweat yellow.

If she had fulminant meningococcaemia - "aemia" means in the blood, "meningococcus" is the name of the organism, "fulminant" comes from the Latin for "struck by lightning" and is similarly grim - if she has fulminant meningococcaemia she has less than a thirty percent chance of survival. And that's without two collapsed lungs.

And I don't know. There is something else going on in this woman. She has had a partial gastrectomy - part of her stomach cut out - because she ws addicted to codeine. Codeine (heroin for beginners) is not sold separately here - the only way you can get it easily here is when it is combined with paracetamol or combined with ibuprofen. This means that once you get addicted to codeine you end up taking vast amounts of these combination tablets - thirty or more a day for months at a time. This means vast amounts of paracetamol (acetominophen), which damages your liver, or ibuprofen, which damages your stomach. Often the damage done by these combination medications causes more pain, which the patient treats with more codeine, and so on.

Anyhow - there is something underlying this. Some psychiatric issue, some substance dependence. She is malnutritioned. She has rotting teeth, mouth ulcers, head lice, she is covered with scabs that look like dermatitis artefacta - a symptom of a psychiatric illness where you pick at yourself. Or maybe formication - often seen with amphetamine abuse, where you pick at the insects you believe are living under your skin.

Her mother swears blind she is not "on drugs", but I have given her my drug and alcohol services number. If she lives through this - which is actually unlikely - I have asked her to call.

Anyway. There is something going on, something profound, something dangerous and deadly that we missed the first time. I hope she lives so that we can find it and fix it.

Thanks for listening,

* White cell count sixty two point five. Anything over eleven is high.

** I've tried to think of another word that best explains this and I can't. There is something numinous about this, something that so far exceeds my ability to put it into words that it is stupid to try. There is something about having your hand inside the chest of another living, breathing person, feeling a hollowness where you should feel substance - I don't know how to say it better.


Blogger Camilla said...

Good lord. I hope you get to find it and fix it too! It sounds very nasty. Am sending good vibes.


12:17 PM  
Anonymous ladyk73 said...

I think you have raw talents above and beyond what you may feel sometimes.....

If she lives (and it sounds veryvery grim) you had a huge part in it. My goodness...an infection like that....to come out onto your shoes and stuff....
Remember the med ward discharged her.

Everyone makes mistakes, we are all human.

But this sounds so very very bad, it would be a mircle if she lives....cr

1:36 PM  
Blogger Benedict 16th said...

Rifampicin is for others, you should be on Ciprofloxacin! Your bloody hospital is too stingy to pony up for it, I still have some from the packets I nicked the last time I was exposed to Meningococcal*.


* they might be out of date by a year or two, but I am pretty damn sure they will still be at least 95% as effective as a fresh batch.

PS The cat is no longer up the Chimney, but I think she is going to need vitamin D suppliments (as she does not come out of hiding)

10:09 PM  
Blogger jenblanck said...

And now I'm thanking God that I'm no longer a hospital nurse. And further thanking Him that I was never an emergency or med/surg nurse.

12:59 AM  
Blogger Bronze John said...

Thanks for the comments. Sadly, my partin this was more brute labour and doing what I was told. Having said that, this woman was and is fairly sick. She remains in the ICU, but the antibiotics seem to have been taking effect. When she wakes up we have dieticians and social workers and hospital at home nurses waiting to spring upon her.


9:50 AM  

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