Resumption of normal service

Excuse my absence. I’ve been moving house, and unsurprisingly my telecommunications provider was not terribly supportive.

I love to write. I just haven’t quite got the hang of interpretive dance yet, which might be part of it, but in any case, I find blogging a lovely way to reflect.

Today, I need to indulge in some reflections which are not new for me, and for that reason may have popped up on here before. To be honest, I can’t remember. But today it is especially important to me.

There have been a number of people in my life who have changed it, irrevocably, and probably have no idea. Many of these are professional acquaintances; mostly I’ve lost contact with them.

On some occasions, I’ve recognised their impact early enough that I could thank them. In writing, always – to convey the depth of my gratitude in person would be nigh on impossible. The temptation to slip into flippancy is irresistable to me.

For the past nine months, I have worked with a colleaguewho is 1 year my chronological junior, and 1 year and a seemingly infinite amount my professional senior. He is also my friend, despite the fact that we communicate almost entirely in insults, derisive statements and threats.

In addition to the important clinical skills and knowledge he has imparted, I am so grateful for his skill in negotiating the difficult ground of being my ‘boss’. Not just in the sense that he socialises with me/us outside of work and then has to direct me, but in the sense that of all people for whom he could have to do this, I am potentially the most difficult. I seem to give the impression of disrespect, even when I don’t mean it. And part of this colleague’s delightfulness is that he has a healthy dose of self-doubt, despite his exceptional skills.

Last shift with him today, and I feel certain we’ll lose touch. I’ve learnt a huge amount from him, and I don’t even have the intestinal fortitude to tell him, even if it would make a difference.

I hope others are lucky enough to find the type of mentors I have found. And I hope you have the courage to thank them.

 

I may be tired, but I promise you I’m not hallucinating.

On the way home from my evening shift just then, I had to stop my car.

To let a koala cross the road in front of me.

Awesome.

A night of scary girl-problems.

Last night, I was working with an otherwise all-male medical team. It was a busy night.

At evening handover, I was given a 28yo lady with a two hour history of generalised abdo pain. She had some diarrhoea, felt nauseated, and gave a history that her 5yo had had the same illness yesterday. She was for IV fluids and discharge.

Over the course of the evening, her pain didn’t improve – not with hyoscine, not with paracetamol, and eventually not even with oxycodone.

I decided to re-examine her – not an easy task, as she was significantly overweight. However, as I checked her vital signs chart, I noted something very significant – that even after 2L of IV fluid, her heart rate had accelerated from 80 beats per minute to 120. The nurse hadn’t thought to alert me to this, which is neither here nor there. I’m just glad I looked.

At this point, the good old ‘Every woman is pregnant til proven otherwise, and every pregnancy is ectopic’ maxim was employed. With my patient unable to wee, I drew some more blood for a pregnancy test. At which precise moment, the path machine exploded in the lab. Bugger.

We inserted a catheter, got a positive urine pregnancy test, and within twenty minutes the patient had cross-matched blood and was being wheeled to the operating theatre. There was 2L of blood in her abdomen, courtesy of a four-week embryo which ruptured a very narrow part of her uterine tube and an associated artery. Young, healthy women die from ectopic pregnancies, and the cause of death is often not diagnosed until autopsy. In this case: Nice save, team.

The next patient I volunteered to see, even though one of my colleagues had ‘clicked her off’ the ‘to be seen’ list. I knew – and probably appreciated more than a man – the triage nurse code on her file.  ‘For review’, especially when applied to a nineteen year old presenting after midnight, is never good. It generally means sexual assault.

Now, I cannot imagine the awfulness that this girl had been through. And I know that my male colleague would’ve been flawlessly professional, and thorough. He would’ve been compassionate, and gentle. But I know that if it were me that had been assaulted, the last person I’d want examining me would be – well, anyone with a Y chromosome.

Interspersed with these patients were your standard kids with coughs, off-leg oldies, and intoxicated delights. Like I said, busy night.

By the morning, I felt wrung out. Nothing I had done was particularly labour-intensive, nor noteworthy. And the feminist in me (decidedly latent though she is) dreaded the notion that I had witnessed two situations where anatomy was unquestionably the determinant of vulnerability.

So instead of wondering whether gender inequality in the social/business/political world is justified, perhaps I’ll chalk this one up to an oversupply of empathy.

Or perhaps to PMS.

Medical ruminations

To clarify my last post somewhat: It wasn’t quite as awful as Fiona’s experience. But it was one of the most gut-wrenchingly terrifying experiences of my career.

A 34 year old woman self-presented to ED with a history of cough. She looked pretty sick. When her vital signs started going off and she went into acute pulmonary oedema, a nurse grabbed me to assist the boss, who was treating her. My sole clinical contribution was to wipe the sputum off her chest and attach the defib pads. Then, as is often the case when one is both an ED doctor in a busy department and in possession of two X chromosomes, I was assigned to ‘family duty’. It may be a generalisation to imply that resuscitation is an opportunity for a bit of a pissing contest among the boys — or it may not. In any case, as more and more ‘chiefs’ became involved, this Indian did a great job of keeping the patient’s family informed.

Little by little, as things got worse, I’d pop out of the resus bay to the ‘quiet room’ to update my patient’s husband. It is truly awful explaining to someone so young that his wife’s heart has stopped, and that she’s receiving CPR, but it must be done unambiguously and gently. My experience in palliative care, and in hearing bad news myself on more than one occasion, makes me relatively competent at this. Not that it ever sounds ‘right’.

Miraculously, my patient regained a heartbeat while her husband was observing CPR. Unbelievably relieved, he called his mum to sit with him. Sadly, a short time later, his wife’s heart stopped again. I explained that we would continue CPR, then do a blood test to ascertain whether her cells could survive this event. I told him that in the event her blood showed that this event was unsurvivable, CPR would stop, and that his wife would die.

CPR was eventually deemed futile – ie, not in the patient’s best interests. Her blood showed that her organs had died from lack of oxygen. They had leaked so much acid into her blood that her cells couldn’t function. Compressions were ceased after consultation with the entire resuscitation team. Time of death was called. I went to deliver the heartbreaking, lifechanging, awful news to her husband and mother-in-law. They asked me to stay with this lady, which I was happy to do.

As is sometimes the case, the heart made a valiant effort to continue beating, even when there was no hope. This was not, and should not have been, an incentive to continue resuscitation. It is undignified for the patient, and the indignity is unquestionably futile.

My pain came from knowing that her family was already grieving, and that according to science, my patient was still ‘alive’. There is no explaining this to the distressed loved ones who see a monitor trace, and cling to the idea that life is hope. I couldn’t face telling them that I was wrong in saying their wife and daughter was dead, when I knew it was inevitable that I would all-too-soon be right.

So we detached the monitor, disconnected the ventilator, and gave her as much dignity as we could. We covered her body, leaving her face exposed, and as requested, I stayed with her. At some point, without the oxygen from the ventilator, her heart stopped.

This whole situation reminds me that medicine is a science, but that it works within the context of human lives – which aren’t wholly scientific. I can’t tell you when my patient ‘died’ – but I can tell you the precise moment where her dignity became more important than the science of heart rate and blood pressure. I hope that on the rare occasions where science fails the medical profession and we can’t save someone, we can always find a few seconds to dignify their life.

The horror…

I’m on holidays, still. So, again, for the benefit of anyone reading this, it happened ‘yesterday’, and was inestimably more horrendous in the emergency medicine setting:

Jumping the gun

So, to ‘lighten the mood’, my reason for stumbling across this video? I was reading this book, which includes large chunks on what it’s like to be totally scatterbrained and lose things all the time, and I lost the book. Three pages from the end.

Then, on the plane, the flight attendant came up to me and asked whether I was ‘Dr [Surname]’. Terrified that someone on the plane was quietly having chest pain/a baby, I reluctantly admitted that yes I was.

That’s when he told me my wallet was also still at said airport, and would be flown in my general direction on the next intercity service. God bless Qantas.

This is when my friends all say, with a note of concern –  ‘and you’re a Doctor??!?!’.

Fitness update.

A while ago, I posted about my fun run aspirations. After a year of committed exercising and weight loss, the wheels fell off at rather an inopportune time, and I had decided to give yesterday’s fun run a miss. The decision was multifactorial – yes, my fitness sucked compared to my pre-pneumonia capacity. In fact, I had the exercise tolerance of an emphysemic heart failure patient. But also, I’d completely lost faith in myself.

Happily, I saw the light. Not only had I booked flights back in April, but I’d committed myself – and the better part of a year of my life – to this goal. Whether or not I was able to run it (I wasn’t), the important thing was proving to myself that I could commit to the seemingly insurmountable awfulness. I have hated every step of every run I’ve ever been on. Most walks, too. But nothing good comes easily, and there’s no-one else to back me if I won’t!

For a bit of context – I have a number of places I call ‘home’. First, my current residence. I work with people I respect, in a well-resourced hospital, in a lovely town. I have just been offered permanency there, which will see me stay for another few years.  My second home is the fun run town, where I worked for two-and-a-half years. I own a house there; I loved the city, and I had some great friends. The work environment – previous post notwithstanding – not so much. Thirdly, my ‘home town’, where my family home still is. And fourthly, my ‘spiritual home’, where I spent many holidays as a child – and where I hope to retire in a million years or so, when I can afford a clifftop house made entirely of glass.

My standard holiday involves rose-tinted nostalgia at the familiarity and friends of a past ‘home’. Indeed, prioritising this fun run above those that were more conveniently located had as much to do with visiting close friends as it did with running 10km. That, and the tax-deductability of a trip to visit my property.

Ultimately, what did I achieve? I ‘inspected’ my house, walked 10km in a reasonable time, and felt a little bit sad that nothing was the same as when I left. I caught up with a few friends, had an early Sunday night, a quick Monday morning coffee with a nurse from the hospital, and drove to the parental home.

In deference to my ill-advised (but immutable) commitment to the 12 week body transformation challenge, which began today, I thought I’d better get some more exercise done. Call it ‘active recovery’. Thoughts:

1) When one goes for a run and has a choice of no fewer than four key pockets in one’s outfit, one can be pretty sure she’s spending too much on exercise attire. Or is a bit too relaxed about home security.

2) ‘Active recovery’ has whiskers on it. Whoever invented it failed to take into account footwear-related blisters. But I’m pretty proud of myself for running anyway. God knows what I’ll wear on my feet to fly home tomorrow. I wish I’d brought ugg boots. There aren’t enough bandaids in the world.

3)  Outdoor running at this time of year is fraught with danger, in the form of angry, angry birds.

4) The ‘mountain’ behind my parents’ house is actually more of a hill. And I can now run all the way around it in exactly twenty minutes, which means that I finish my 30 minute run at something of an apogee. On the upside (which I failed to see until I’d completed the subsequent halfway-round-the-mountain walk), it means that my fitness has improved.

In any case, I stand by my assertion in the link above. Regardless of my ambivalence toward the fun run town, I’ll be back next year, and I’ll run the whole. bloody. way. And, I’ll do it in under 45 minutes. I have something to prove, if only to myself.

 

 

 

 

A holiday medical story…

Okay, so this blog is theoretically about emergency medicine. Of late, it’s been more about self-indulgent ranting. It reminds me of that Ben Folds/Nick Hornby song about bloggers. Oh well, such is the perogative of bloggers!

So, yesterday afternoon*, I was working in ED when I ‘picked up’ (ie assigned myself to) an elderly lady who’d had a fall. She was a category 3 (to be seen within 30 minutes), still on an ambulance trolley.

The history had a few concerning features that made me think perhaps she was worthy of a) a category 2 (10 min) and b) a bed. ’88yo F, fall at home early this morning, ambulance noticed deformity to R thigh.’

Off I toddle to see the patient. Yep, she’s elderly. Yep, she’s clearly got a grossly displaced, closed fracture of her R femur. She’s also pale as a ghost. Of more import, however, was the fact that she had a heart rate of 120 (fast) and a blood pressure of 80/55 (low).  Her limbs were cold to the shoulder and hip respectively; she was drowsy and confused; and she’d fallen after going to the toilet 8 hours previously and hadn’t passed urine since. This patient was shocked, already in some degree of renal failure, and had the potential to have rhabdomyolysis.

I put in a line, took bloods, applied a warm blanket, ran some fast IV fluid in, and ordered an XR. As I was writing the blood form, her son arrived.

“She’s not to have any blood products.”

(Shit).

A little rundown for the non-medical among you: long bone fractures (especially the femur), bleed. They need operative repair, at which point they bleed some more. This patient was shocked partly because of ‘hypovolaemia’ (low circulating blood volume, in this case due to blood loss into the tissues of her thigh), and although it probably looked a bit worse because she was hypothermic, she needed blood.  However, as her son was a Jehovah’s Witness, and he was her power of attorney, she would not be able to receive it.

At this point, with her numbers not improving, I went to the boss of the department, and uttered those magic words, guaranteed to bring help in a flash:

“I’m out of my depth and I need your help”.

Ultimately, I was doing the right thing by filling her up with normal saline. I spoke to the patient and to the son about the potential for catastrophic bleeding causing death. I organised traction. I spoke to the unbearably unpleasant orthopaedic registrar.

Unbelievably, she did okay. There was no rhabdo; her haemoglobin got down to about 54, but she got better; she was discharged to the rehab ward about two weeks later. Amazing.

I tell this story to illustrate two points: Firstly, even though in retrospect I detest the working environment in the ED I was working in at the time, my bosses would help when I needed it. Secondly, for anyone who doesn’t know, orthopaedic registrars are evil. This will no doubt be a recurring theme in any medical posts, so might as well introduce it early.

 

*The upside of being on holidays is that I can write posts like this one. Clearly, this did not happen yesterday, because I’m still on holiday – so if you think you know the patient, the location, or whatever, you’re probably wrong. Also, at the time, I was very, very new to emergency medicine. 

 

Holidays!

Ah, it’s lovely to be on holidays.

I’ve come back to (one of) my old hometown(s) to catch up with people. Having flung myself round town, meeting various friends in various convenient (to them) locations, this afternoon I thought it was time for a little self-indulgence.

I went to see a movie.

My choice was fraught with uncertainty. The two that appealed – ‘One Day‘ and ‘The Help‘ – are both books I have read, and loved. In all my book-to-screen experiences, only one has translated well. But any film that contains both Anthony Hopkins and Emma Thompson can’t help but be a winner.

I chose ‘One Day’. The book is by David Nicholls, a writer whose first book had an endearing (and startlingly familiar) protagonist in Brian Jackson. Familiar in that – but for the name and nationality – I fell in love with the same man during the first year of my undergrad degree. Don’t judge me, I saw the light eventually 🙂

The deciding factor between the two movies was that I *loved* The Help. It’s a beautiful book. One Day had some overdrawn, clunky characters and laboured points, and to be honest I struggled through the first 184 pages. Page 185 changed all that. I finished that book five minutes after I should’ve left for work, and arrived 20 minutes later with a tearstained face and a heavy heart that persisted until teatime. I doubted the movie could capture that, but it seemed preferable to ruining a book that I enjoyed more than any other in the past five years.

So, the film. Armed with the requisite maltesers and an implausibly large Coke Zero, I entered the enormous cinema – and was the only one there. Love it. The characters were much more endearing on screen than their written counterparts; the contrasts more subtly nuanced and the themes less arduous. The page 185 moment, though less shocking in my case for being expected, was done reasonably well. The requisite rain (requisite both for being set in England, and for the sadness) did nothing for the bladder distension common to all movie goers. You’d think we’d live and learn.

Ultimately, I enjoyed the film more than the book. But there was something about the achievement of reaching page 185 which made it more special. A book that I was ready to pan outright, and with which I was disappointed and frustrated, transformed in a single sentence to move me more than any other book has.

Confused?? There’s nothing worse than a spoiler. So, in the interests of good practice: Either read the book or see the film. Both have their merits. Then tell me what you think 🙂

 

Rage

So, I haven’t posted for a while on account of a horrendous run of 12 night shifts in 14 days. How time flies when one is having fun.

But now, I’m on a well-earned break!

So, there is a whole bunch of newbie doctors just recruited to our hospital. They’re from the UK. In my standard hospitable fashion, I invited some of them for dinner last night.

Here beginneth the rant:

1) If I’m cooking an expensive three-course meal for ten people, randomly inviting strangers along is fine, provided you give me sufficient notice. Otherwise, I am forced to go without my serve of the entree (that was going to be a main, but for the last-minute addition of three mouths to feed)…

2) *If* you bring an uninvited stranger, and they moan voiciferously about – variously – Koalas, Vegemite, Chocolate, the weather, New Zealand, and the lack of respect Australians have for the royal family, it might be worth suggesting quietly to them that they either thank the host or assist with some aspect of meal preparation/cleanup.

So, I went to bed a little pissy. From experience, I expected to awaken replete with Pollyannaism, and glad to be alive. Sleep is good to me like that. And, I did. Glad that meeting the *definition* of a whinging pom will help me to recognise that sometimes I can be less positive than I’d like.

Then, I got up, washed my hair… and the hot water ran out. Clearly the gas bottle is empty. Bastard. Hair full of shampoo, and I have to boil the kettle, dilute the boiling water in the bathroom basin, and use a kitchen jug to pour still-slightly-too-hot water over myself.

So, I go to ring the property manager, who is responsible for these things. She’s not at work yet. So I ring the local gas supplier.

“Unfortunately, [Insert name of evil service provider here] is currently experiencing an unprecedented volume of calls. Please call back later”

Bullshit.

If it were unprecedented – which, to be honest, seems a little unlikely at 0730hrs – you wouldn’t have a voicemail message for the occasion.

So, while I’m ranting – today is payday for the doctors at one of my previous places of employ. Said place owes me three weeks annual leave pay, and has done for more than six months. I have been chasing them, pleasantly, for five weeks (and two whole payruns).

I didn’t get paid today.

To say that my email was strongly worded is an understatement.

Thank God I’m on holidays. It’s probably safer for the patients that way.

 

Mania

I should admit that, from time to time, my colleagues wonder if I’m manic. As in, I am happy all the time, and talk like a drain. Think Pollyanna, without the limp.

Today, I saw a young man who represented with a rash. He was seen by my colleague in the wee small hours of this morning, and prescribed prednisone for a presumed drug reaction (ie, it was thought his rash was due to a recent course of metronidazole, an antibiotic).

He had gone to the chemist to fill his script, and the chemist was alarmed by the extent of the rash. She recommended my patient see his GP.

The GP suggested 50mg prednisone twice a day, so my patient took it as directed. He also applied some steroid cream to the rash.

This evening, dear Mr X was truly, horribly, iatrogenically manic. As in, between the 150mg of prednisone and the 600mg of hydrocortisone he’d applied to his skin, he had overdosed on steroid. I stood there, dumbfounded, as this usually very functional man spoke for fifteen straight minutes about his rash. Without pausing for breath.

When I attempted to calm him, he was most affronted. He didn’t feel he was any different from normal.

If this is truly the case, I pity his wife.